Bariatric Training and Education
Hallein Clinic, Austria
Karl Miller, MD, FACS
Obesity surgery is not only a craft but it also signifies consideration of the disease asa whole. An Operation Primer undertakes the task of communicating
basic surgical techniques. Only someone who knows all the technical possibilities andprocedures is in a position to react flexibly and adequately in different situations.
About 50 different surgical methods have been developed in obesity surgery in the past 50years. It is obvious from this that the optimal surgical method for the obese patient does
not exist. Experience has shown that peri- and postoperative complications can be reducedwith with simplified working steps. An Operation Primer is an ideal format forcommunicating new operative methods but it does not replace training by an experienced
surgeon. A surgeon cannot rest on his laurels but must always keep up with the latest
techniques. I would therefore like to take this opportunity to thank the Industry formaking Mental Training, training on the computer simulator and operations in thelaboratory possible. First-class surgery is possible only through careful acquisition ofknowledge, regular training and quality control. Additional mental training is aneffective way of optimizing the outcomes of further training for laparoscopic procedures.
It is associated with fewer costs and with better outcomes in some crucial assessment
scales than additional practical training.

Bariatric Surgery clinical fellowship in the USA

Seiichi Kitahama, MD
Minimally Invasive Surgery Fellow
Michael E. DeBakey Department of Surgery
Baylor College of Medicine, Houston, TX

Bariatric surgery has been gaining popularity worldwide.? It is still
not easy to master the comprehensive perioperative bariatric patientcare and advanced laparoscopic skills including intracorporeal hand-sewn
anastomosis.

Currently there are 62 bariatric surgery fellowship training programs in
the USA according to the Fellowship Council ([a:http://www.
fellowshipcouncil.org/]http://www.fellowshipcouncil.org).? The
organization monitors individual fellowship training and regulates thematching process to ensure high volume and high quality training. ?

I completed one year clinical laparoscopic bariatric surgery fellowship,
predominantly LRYGB and LAGB, with some LSG at Legacy Good Samaritan
Hospital in Portland, Oregon.? Subsequently I am undergoing anotherclinical MIS/bariatric surgery fellowship predominantly LRYGB and LSG,
with some LAGB at Baylor College of Medicine in Houston, Texas. ?Bothhospitals are accredited as Bariatric Surgery Center of Excellence by
Surgical Review Corporation.

I would like to share my experience with 7 bariatric surgeons anddiscuss the way to organize a bariatric training program.

Bariatric Fellowship in Australia
Dr Benjamin Woolven
St George Private Hospital
General Surgical Training in Australia requires a six year undergraduate or 4 year post
graduate medical degree and two years of post graduate experience before commencement.
General surgical training is undertaken over a minimum of 5 years and requires successful
completion of a two part clinical examination. Further post fellowship training is at thediscretion of the individual surgeon though non compulsory two year programs in uppergastrointestinal, colorectal and hepatobiliary surgery have been established. There is nocentrally administered training program in bariatric surgery though a number of individual
institutions offer one year fellowship programmes.
The authors experience is of a one year programme undertaken at St George Private Hospitalin Sydney in Upper Gastrointestinal and Bariatric Surgery. During the fellowship there
were 275 bariatric operations including 52 laparoscopic adjustable bands, 158 laparoscopic
sleeve gastrectomies, 29 laparoscopic gastric bypasses and 61 revisional operations. There
were 433 non bariatric operations. International candidates from Singapore, New Zealandand the United Kingdom have previously completed the programme. Future international
candidates are welcome to apply for the St George Fellowship program and other bariatrictraining programmes throughout Australia.

Bariatric Fellowship Training in a Center of Excellence, Taiwan Experience

1

Bariatric & Metabolic International Surgery Center, E-Da Hospital, Kaohsiung, Taiwan.

2

Department of General Surgery, E-Da Hospital, Kaohsiung, Taiwan.

3

Department of Chemical Engineering, Institute of Biotechnology and ChemicalEngineering, I-Shou University, Kaohsiung, Taiwan.
Chi-Hsien Lo1, Chih-Kun Huang1,2,3

Background: Bariatric surgery has gained more popularity in Asia-Pacific area. But, themultiple co-morbidities of morbid obesity and steep learning curve make comprehensivetraining program to be looked-for in recent years. Hereby, we present the fellowshiptraining program in a unique International Bariatric Surgery Center of Excellence(BSCOE) in Taiwan.
Methods: From July 2009 to July 2010, fellowship training process, learning curve,
patients demographic data, operation time and surgical complications were all collectedfrom different stages of the learning. According to the bariatric training protocol ofthe institution, data was analyzed and compared.
Results: In this one-year period, totally 346 laparoscopic bariatric operations wereperformed in the BMI Surgery Center, E-Da Hospital. As a primary surgeon, the fellowshipperformed 169 bariatric cases independently after 43 assistance. Different type of
bariatric surgeries were performed, as gastric banding with or without gastric plication,
sleeve gastrectomy and Roux-en-Y gastric bypass. There were only 5 surgicalcomplications (3.55%). There was no mortality. In this journey, we reviewed different
stages of the fellowship training, as being from a mere assistant, progressed to primary
surgeon, and then supervisor.
Conclusion: Low complication rates came from excellent supervised bariatric training
program and we proposed a bariatric surgery training guideline in Asia-pacific area.

Better Short-term Weight Loss for Patients with Group Therapy after Gastric Banding

Digestive and Bariatric Surgery Division, Taipei Medical University Hospital, Taipei,Taiwan
Weu Wang M.D.

Background:
Adjustable gastric band surgery is one of the standard surgeries for the treatment ofmorbid obesity. The results between, however, varies. Post-operative intensively
follow-up and group therapy may offer the patients better concept of eating behavior
and life style change, and further lead to better weight loss.

Materials and Methods;
From January 2008 to Dec 2009, 156 patients had received gastric banding surgery. Amongthese, 31 patients joined the post-operative group therapy including nutritionalcounseling, aerobic exercise and diet education willingly. Another 31 patients was
selected without post-operative group therapy as comparative group. The data wascollected retrospectively.

Results;
The mean BMI was 43.6+5.3 kg/m2 in the study group and 42.8+6.5 kg/m2 in comparison.
The BMI at one year after surgery was 32.8+3.6 kg/m2 and 34.2 + 4.6 kg/m2 respectively.
The average adjustment was 5.2 times in study group comparing to 3.8 times. The study
group has better loss of body fat and higher percentage of muscle component.

Conclusion:
Post-operative group therapy is effective for better weight loss and greater improvementof body fat percentage for patients undergo gastric banding.

Laparoscopic adjustable gastric banding in a Japanese instituteDepartment of Surgery I, Oita University Faculty of Medicine, Oita, Japan.
Masayuki Ohta, MD, Teijiro Hirashita, MD, Yukio Iwashita, MD, Tadashi Ogawa, MD, Kazuhiro
Yada, MD, Takashi Masuda, MD, Hidetoshi Eguchi, MD, Seigo Kitano, MD

Background/Aim: Although bariatric surgery has not been popular in Japan, the most popularbariatric procedure is now laparoscopic sleeve gastrectomy. In 2005, we introduced
laparoscopic adjustable gastric banding (LAGB) into Japan, and here, our data werepresented and evaluated.
Methods: Between August 2005 and December 2010, 31 morbidly obese patients (18 women /13 men, mean age of 39yr) received LAGB in our institute. All patients were morbidly obese(BMI>35 kg/m2), and the averaged weight was 118 kg and BMI was 43 kg/m2. In regard to LAGB
devices, LAP-BAND® (Allergan Medical) was used in 29 patients and SAGB® (OBTECH MedicalGmbH) in 2 patients. All procedures of LAGB were performed through the pars flaccida pathway
with band fixation using gastric-to-gastric sutures. Averaged follow-up duration was 35
months.
Results: All the procedures were completed laparoscopically. Two complications wereexperienced (postoperative bleeding and port trouble), and reoperations were needed inthe patients. Weight loss and % excess weight loss on the average were 25kg and 44% after
1 year, 33 kg and 57% after 3 years and 29 kg and 51% after 5 years. Accordingly,
comorbidities were frequently improved, and type 2 diabetes and metabolic syndrome wereresolved in 9 of 10 patients (90%) and in 14 of 17 patients (82%), respectively.
Conclusions: LAGB is safe and effective in Japanese patients with morbid obesity, and ourdata seem to be equivalent to those previously reported in Western countries.

Patient Selection for Laparoscopic Adjustable Gastric Banding
Centre for Obesity Management and Surgery, National University Hospital, Singapore
Asim Shabbir, Litang Chen, Raymond Lim, Jia-yan Wee, Lifeng Zheng, Davide Lomanto,
Jimmy BY So.
Surgery is the most effective treatment for morbid obesity. Various bariatric
operations are available but the ideal operation remains unknown. Laparoscopic
Adjustable Gastric Banding (LAGB) is one of commonest bariatric operations. It issimple, adjustable, reversible and minimally invasive. However, the outcome of weightloss is highly variable and band-related complications occasionally occur. To achieve
the best outcomes, careful patient selection and a committed follow-up program areessential. Our centre started LAGB since 2004. In 2007 and 2008, we introduced
laparoscopic sleeve gastrectomy (LSG) and gastric bypass (LRYGB) respectively. We
reviewed our patients who underwent bariatric surgery in the past 6 years, andcompared the results among these 3 procedures. We investigated potential predictors ofoutcomes after LAGB and we also reviewed published date for additional predictors.
Till 2010, we had 72 patients who underwent bariatric surgery (42 LAGB, 22 LSG, 8LRYGB). The median age was 44(range: 24-68) and the BMI was 41 (range: 30-57). Medianfollow-up among the three procedures was 45, 8 and 6 months respectively. The medianexcess weight loss (EWL) was 29, 34, 44% respectively. Among patients who underwent
LAGB, 29 patients (69%) defaulted follow-up in long-term. Twenty-two (52%) patients
had unsatisfactory weight loss (<30%EWL) and 6 (14%) patients developed band
complications and required band removal. In general, predictive factors for pooroutcomes include age, unwilling to change lifestyle habits and loss of follow-up. In
conclusion, long-term results of LAGB are unsatisfactory in unselected patients.
Careful patient selection is essential in achieving good outcomes in LAGB.

Lap banding in Thailand
Institute: Bunrungrad International Hospital, Bangkok
Professor Paisal Pongchairerks
Laparoscopic Gastric Banding was the first bariatric procedure done in Thailand in2003. Its preference decreased gradually as Thai surgeons acquired more expertisein other more difficult procedures. The popularity of laparoscopic sleeve
gastrectomy also seemed to contribute to this trend. However, banding still
entertained the benefit of being a relatively easy procedure among all. Surgeons
seemed to come across more long-term complication after more years of follow-up,
including esophageal dilatation, reflux with or without esophagitis, slippage andband erosion. Some cases of reoperation were experienced. Nowadays, Thai surgeons
have different opinions as for the indication of gastric banding.

Gastric Band in India
Bombay Hospital Fortis Hospitals, Mumbai, India
Ramen Gyanendra Goel
Bariatric surgery started late in India. VBG was introduced in late 1990s. First gastric band
surgery in India was done in 2000 & subsequently till 2005 almost all surgeons started
bariatric career with gastric band. Most of experienced laparoscopic surgeons could adept
gastric band comfortably & numbers of band surgeries increased rapidly till realization
started settling in that band is not effective in almost 25% - 35% with 3 year explantation
rates of 20% - 30% in different hands.
Introduction of gastric bypass & sleeve gastrectomy has led to further decline in gastricband surgery’s fortunes in India. Gastric band now accounts for less than 1% of proceduresin most of bariatric practices. Few recent centers have shown renewed interest in gastricband implantations with successful outcomes.
Various reasons attributed to poor results seen by Indian surgeons may be attributed to poor
follow up due to failure to get regular adjustments due to long distances, incompletelydeveloped bariatric program, high rate of oesophageal dilatation etc. Lack of patience, due
to slow weight loss results, compared to other bariatric surgeries may also attribute to highexplanation rate.
Gastric band surgery accounts for almost 50% of bariatric procedures in USA, but only longterm follow up will show whether fate of bands will follow the Indian graph. As gastricsleeve is becoming the procedure of choice amongst bariatric surgeons & patients in India,
the future of gastric band surgery in India is bleak.