Organising a Bariatic-Center: A Swiss Perspective

Georgios Peros; Teresa Cereser; Ioannis Lazaridis; Thomas Baechler

doi:10.20944/preprints202411.1788.v1

Submitted:

21 November 2024

Posted:

25 November 2024

You are already at the latest version

Abstract

Background: The ongoing obesity epidemic leads to increasing numbers of bariatric procedures, which nowadays belong to the most commonly performed visceral surgeries in western countries. To deal with the increasing caseload and to measure up with the expectation of patients and referral doctors, an increasing number of hospitals need to offer such procedures in future. This narrative article summarises requirements, considerations and strategies for organising a modern obesity center based on the example of a swiss tertiary referral center. Objectives: To describe the process needed to organise a multidisciplinary bariatric centre ex novo in a tertiary hospital. To overview the necessary steps a and how to overcome limitations which occur during the process. Methods: The assembly of the bariatric centre started in the second half of 2021 with operational start in 2023. It included the setup of an interprofessional team with endocrinologist, nutritionist and physiotherapists to evaluate people with morbid obesity. Pathways for the preoperative assessment were adjusted to address the specific requirements of bariatric patients. For the hospital stay Enhanced Recovery After Surgery (ERAS)- like pathways were designed. Healthcare professionals were trained for the preoperative assessment, treatment during the hospital stay and postoperative care. Further healthcare professionals were recruited where needed. To achieve this partnerships with already established centres were built up. Current literature was thoroughly studied and requirements of national and international recommendations were fulfilled. In addition, surgical sets for bariatric surgery had to be composed. Appropriate facilities were integrated in the planning of the new building of the hospital. Results: Over a period of about 18 months, we were able to create from scratch a bariatric centre that can cover all aspects of the treatment of patients with obesity, from conservative therapy to bariatric surgery and long-term follow-up. Patients which fulfilled criteria of Highly specialised medicine (esp. revisional surgery, BMI >50kg/m2, age>65 years) where operated in the associated reference center, when indication, was not urgent. Conclusions: Organising a bariatric centre needs a multidisciplinary setup. The core team has to be made up by professionals with experience in the field of obesity and bariatric surgery. Training of all involved professionals and disciplines has to be secured. In this intention, fellowships and cooperations with other bariatric centers are indispensable. Before implementation of bariatric surgery diagnostic flowcharts for preoperative assessment, clinical pathways for the peri- and postoperative care and the follow- up- care have to be defined in a detailed manner.

Keywords:

Organising

;

Bariatric

;

Adiposity

;

Swiss

;

Bariatric Centre

Subject:

Medicine and Pharmacology - Surgery

This article is a revised and expanded version of a paper entitled Organising a Bariatic-Center: A Swiss Perspective, which was presented at the XXVI IFSO World Congress, Naples, Italy, August 30 – September 1 2023 [1].

Introduction

The rising global prevalence of obesity represents a significant public health challenge, with profound implications for individuals' health and healthcare systems worldwide [2]. As obesity rates continue to soar, the demand for effective treatments and comprehensive care for individuals struggling with severe obesity has never been greater [3]. Bariatric surgery has emerged as a viable option for long-term weight management in this population, offering substantial benefits in terms of weight loss and improved metabolic health [4].

Only about 1% of eligible patients receive bariatric surgery [5]. Efforts to offer the highly effective surgical treatment to affected obese patients have to be made and access to such treatment has to be facilitated.

Switzerland has recognized the urgency of addressing the obesity epidemic and has made significant strides in establishing specialized centers dedicated to bariatric care [6]. This article sheds light on the Swiss perspective on the basis of the organization and operation of bariatric centers, drawing from the country's rich experience in healthcare management and its unique healthcare system.

The development and effective management of bariatric centers are of paramount importance in the context of combating obesity and its associated comorbidities [7]. Swiss healthcare experts have always propagated a multidisciplinary approach to tackle the complexities of bariatric surgery, encompassing medical, surgical, psychological, and nutritional aspects. Follow up and aftercare by nutritionists and visceral surgeons is covered by healthcare insurance nationwide.

The reported data and concept are based on the experience gained in setting up the bariatric centre at the cantonal hospital in Winterthur (KSW), Switzerland. KSW This is a tertiary care hospital serving a population of approximately 500,000 inhabitants in the surrounding urban and suburban areas.

To provide a comprehensive overview of organizing a bariatric center from a Swiss perspective, we herein explore the following key aspects:

Multidisciplinary Care: We discuss the collaborative nature of bariatric care in Switzerland, involving a team of healthcare professionals such as bariatric surgeons, endocrinologists, dietitians, psychologists, and nurses, working in synergy to provide holistic patient care.
Recruitment and training of Professionals
Recruitment of patients, need for a new center
Patient Selection and evaluation: This section will focus on the meticulous evaluation process undertaken to identify suitable candidates for bariatric surgery, considering both medical and psychological factors.
Quality assurance and accreditation: We will explore the rigorous quality assurance protocols and accreditation standards that Swiss bariatric centers adhere to, ensuring patient safety and optimal outcomes.
Postoperative care and long-term Follow-up: The importance of continuous support and long-term follow-up for bariatric patients will be discussed, emphasizing Switzerland's commitment to maintaining patient health and well-being beyond surgery.
Public Relation
Healthcare policy and funding: We will examine the Swiss healthcare system's role in supporting bariatric care, including insurance coverage, funding mechanisms, and policy considerations.

Through a thorough exploration of these critical elements, this article aims to provide valuable insights into the establishment and management of bariatric centers, offering a Swiss perspective that can guide healthcare professionals and policymakers in their efforts to combat the obesity epidemic on a global scale. Switzerland's dedication to excellence in healthcare, combined with its unique approach to bariatric care, serves as an exemplary model for countries striving to develop effective solutions to the pressing challenge of obesity.

Multidisciplinary Care

Obesity is a chronic disease characterized by a wide range of obesity- related comorbidities. metabolic diseases like type 2 diabetes mellitus, cardiovascular disorders, obstructive sleep apnea syndrome and gastroesophageal reflux have to be taken in account [8,9,10,11]. Moreover, nearly all organ systems get affected by severe obesity and lead to functional impairment. Therefore, the assessment of bariatric patients not only needs a holistic first evaluation but also often preoperative diagnostic by health care professionals of different disciplines.

Similarly, modern treatment of obesity is multidisciplinary [12]. The long-term success depends on accompaniment by professional nutrionists and physiotherapeutic training.

Additionally, benefits and risks of bariatric surgery have to be balanced with evolving medical treatments, which nowadays are increasingly used as a neoadjuvant or adjuvant treatment of metabolic surgery [13]. Thus endocrinologists must be integrated in a bariatric center to offer such treatments.

Beside bariatric surgeons, bariatric surgery including peri- and postoperative care of bariatric patients requires a skilled team ofanesthesiologists, technical assistants and nurses, which handle the particularity of obese patients. Regarding long-term care, dermatochalasis is an important issue and has to be addressed by plastic surgeons

Recruitment and Training Of Professionals

The disciplines included in the preoperative assessment included endocrinologists, pneumologists, gastroenterologists, cardiologists, gyneco- obstetrics, psychiatrists and bariatric surgeons. Professionals with previous experience in the field of bariatric surgery and obesity were already employed. Thus, there was no need for recruiting new staff. The professionals which are involved in the treatment of patients with obesity (endocrinologists, nutritionists and physiotherapists) did not need additional training, as they were involved in such treatment for many years in partner hospitals. However. to harmonize different treatment strategies and refresh knowledge and skills, we organized job shadowing in our partner hospital, which also serves as our reference center. Moreover, for all these disciplines in- service training with lectures and interactive meetings were organized.

Recruitment of Patients, Need for New Centers

Switzerland’s government and hospitals are based on a federalistic system. In 2021 there were 33 primary and 19 reference bariatric centers, which could be considered a large number if the total number of 4000- 5000/ year is taken into account [14]. On the other hand, penetration of bariatric surgery for eligible patients remains very low and is thought to be 1-2% [5]. Our hospital provides services for approximately 200 000 inhabitants. As a result, we calculated that 2 400 patients in our region would be eligible candidates. Due to the particularities of the federal Swiss system a local offer of such procedures is likely to increase a higher penetration depth of bariatric surgery.

Most of the general practitioners in our region primarily refer patients to our hospital. As a result, it was to expect that the local offer of bariatric surgery would increase the awareness of general practitioners for these treatment options. Furthermore, those practitioners who previously referred patients outwards were though to refer to our hospitals.

A total of 79 primary bariatric operation in the first three semester from January 2023 until June 2024 with increasing numbers for all periods prove this expectations. Moreover 16 cases which matched HSM criterias (BMI >50kg/m2, age, revisional surgery) were operated in our associated reference center in presence of the local head of department as a joint venture.

An analysis of the provenance of our patients which mostly lives in the insinuates that patients were acquired in the hospital area and not by draining the catchment areas of other hospitals. May the local offer of bariatric surgery enhanced penetration depth of the treatment of patients with obesity in the area.

Patient Selection and Evaluation

Indications and contraindications of bariatric surgery in Switzerland are defined by the Swiss Society for the Study of Morbid Obesity and metabolic disorders (SMOB). There are in accordance with international guidelines and adapted to new evidence [15]. Although it is still under debate how intensive the pre-operative assessment should be [16], otherwise than elsewhere SMOB also defines mandatory preoperative exams. Examples for such indispensable work-up is a preoperative gastroduodenoscopy, a nutritional work up and a consultation by a psychiatrist. Pneumological and cardiological exams are optional but commonly performed in Swiss bariatric centers. Hence, all patients in our center over 50 years of age undergo an extended cardiological and pneumological workup, which has led to the detection of several cardiovascular diseases with need for cardiac intervention or even surgery.

Quality Assurance and Accreditation

Quality

Quality assurance in bariatric surgery requires a multifaceted approach aimed at consistently delivering high-quality care to patients. This involves meticulous attention to every aspect of patient management, from preoperative evaluations to postoperative follow-ups. [15] The primary objectives of quality assurance in bariatric surgery include:

1. Enhancing Patient Safety: Ensuring the safety of patients is paramount. By implementing standardized protocols, identifying potential risks, and closely monitoring patients throughout their surgical journey, healthcare providers can reduce complications and improve overall patient outcomes.

2. Optimizing Surgical Outcomes: Quality assurance measures encompass surgical techniques, equipment, and healthcare provider competence. Monitoring and auditing surgical procedures help identify areas for improvement, ultimately leading to better results for patients.

3. Patient-Centered Care: Quality assurance also focuses on patient satisfaction and experiences. It involves educating patients, providing comprehensive preoperative and postoperative care, and fostering open communication, thereby ensuring that patients are well-informed and involved in their own care.

Accreditation in Bariatric Surgery

Accreditation plays a pivotal role in upholding the highest standards of care in bariatric surgery. Accrediting bodies, such as SMOB and the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO), set stringent criteria for healthcare facilities and professionals to meet. These criteria encompass various aspects of bariatric surgery, including the following [15]:

Surgical Outcomes

With 5.1% of complications Clavien Dindo grades >IIIa international benchmark criterias were furfilled [17]. Moreover 16 cases which matched HSM criterias (BMI >50kg/m2, age, revisional surgery) were operated in our associated reference center in presence of the local head of department as a joint venture. The median hospital stay was exactly 4 days (3- 19).

1. Facility Accreditation: Accredited bariatric centers must adhere to specific infrastructure, equipment, and staffing requirements. This ensures that surgeries are performed in a suitable environment with the necessary resources.

2. Provider Credentialing: Healthcare providers, including surgeons, nurses, and dietitians, are required to meet specific educational and training criteria. Credentialing ensures that patients receive care from competent professionals.

3. Data Collection and Reporting: Accredited centers are often required to collect and report data on patient outcomes and complications. This data is used for continuous quality improvement and research, contributing to the advancement of bariatric surgery.

Postoperative Care and Long-Term Follow-Up

While the surgical procedure itself is a critical step in the journey to weight loss and improved health, postoperative care and long-term follow-up are equally crucial for the success and safety of patients.

Immediate Postoperative Care

Immediately following bariatric surgery, patients require attentive and specialized care to ensure a smooth recovery. Key elements of postoperative care include:

1. Monitoring: Continuous monitoring of vital signs, pain levels, and potential complications such as bleeding, infection, or leakage from surgical sites is essential in the immediate postoperative period.

2. Nutrition: Patients are gradually transitioned from a liquid diet to solid foods over several weeks. A registered dietitian plays a pivotal role in guiding patients through this process, ensuring they receive adequate nutrition while adapting to the anatomical changes in their gastrointestinal tract.

3. Pain Management: Managing postoperative pain is vital for patient comfort and early mobilization. Pain medications are prescribed as needed, and patients are encouraged to participate in breathing exercises and gentle movement to prevent complications like deep vein thrombosis.

4. Psychological Support: Patients often experience emotional and psychological challenges during the recovery phase. Access to mental health professionals and support groups can be instrumental in helping patients cope with these issues.

Long-Term Follow-Up

While the immediate postoperative period requires intensive care, long-term follow-up is equally critical for patients' sustained success and well-being after bariatric surgery. The following components are essential for comprehensive long-term care:

Regular Medical Check-Ups: Patients should schedule follow-up appointments with their bariatric surgeon, primary care physician, and other specialists as needed. These visits monitor weight loss progress and address any medical concerns or complications that may arise.

2. Nutritional Guidance: Continuing to eat a balanced diet that meets the nutritional needs of the patient is essential for long-term success. Regular consultations with a dietitian can help patients adapt to their modified digestive anatomy and maintain a healthy diet [18].

3. Exercise and Lifestyle Changes: Encouraging physical activity and adopting a healthy lifestyle are fundamental for maintaining weight loss and improving overall health. Patients benefit from guidance and support in developing sustainable exercise and dietary habits.

4. Behavioral and Psychological Support: Long-term success often hinges on addressing underlying emotional and psychological factors related to obesity. Support groups, counseling, and therapy can help patients navigate these challenges.

5. Monitoring for Nutritional Deficiencies: Patients are at risk of nutritional deficiencies, such as vitamin and mineral deficiencies, following bariatric surgery. Regular blood tests and supplementation, if necessary, are crucial to preventing complications associated with these deficiencies [19].

6. Surveillance for Complications: Long-term follow-up enables early detection and intervention for potential complications such as hernias, bowel obstructions, or strictures that can occur years after surgery.

Postoperative care and long-term follow-up are integral components of the bariatric surgery journey. They ensure the safety, success, and overall well-being of patients as they embark on the path to weight loss and improved health.

Public Relations

The news of the built-up obesity center in our hospital had to be spread and advertising the multimodal treatment of obesity was essential to ensure the success of the project. To achieve this, we held public events and events for general practitioners. Having in mind the increasing importance to be present as bariatric surgeon in social media,weeditedthehomepage of our hospital accordingly and established appropriate accounts on LinkedIn and Facebook [20]. Due to a lack of time to maintain further social media channels, many other social medias (TikTok, X) remain currently unused.

Healthcare Policy and Funding

Bariatric surgery in Switzerland has a relatively short but dynamic history. The first bariatric surgery procedures in the country were performed in the 1970s and 1980s. However, it was not until the 1990s that the field started to gain recognition as an effective treatment for severe obesity. This shift in perception was partly driven by the growing understanding of obesity as a chronic disease and the increasing prevalence of obesity-related health issues in Switzerland.

The development of bariatric surgery in Switzerland has been significantly influenced by the country's healthcare policies and regulations. Switzerland operates under a universal healthcare system, where citizens have access to high-quality healthcare services. The Swiss Federal Office of Public Health (FOPH) plays a central role in shaping healthcare policies and regulations, including those related to bariatric surgery. The FOPH has issued guidelines and recommendations for the management of obesity, which include surgical interventions when conservative treatments fail to achieve weight loss goals [21].

The FOPH also oversees the Swiss Health Technology Assessment (HTA) program, which evaluates the effectiveness and cost-effectiveness of healthcare interventions, including bariatric surgery procedures. These assessments help inform decisions about the reimbursement of bariatric surgery by health insurance companies. The HTA reports have been instrumental in establishing the evidence base for the effectiveness of bariatric surgery in Switzerland [22].

Bariatric surgery in Switzerland has benefited from collaborative efforts among healthcare professionals, researchers, and policymakers. SMOB has played a pivotal role in promoting research and education in the field of bariatric surgery. SMOB has also been involved in advocating for improved access to bariatric surgery and supporting the development of best practice guidelines [15].

Healthcare policy and regulations in Switzerland have played a significant role in shaping the landscape of bariatric surgery. As obesity rates continue to rise, the field of bariatric surgery is likely to evolve further, with continued collaboration between healthcare professionals, researchers, and policymakers. For Winterthur Cantonal Hospital it is very important that interprofessionalism but also the SMOB guidelines are respected. This evidence-based approach to healthcare policy in Switzerland ensures that bariatric surgery remains a viable and effective option for individuals with severe obesity.

Conclusions

The establishment and organization of a bariatric center in Switzerland presents a unique set of challenges and opportunities within the country's healthcare landscape. This article provided a comprehensive overview of the key factors that need to be considered when organizing a bariatric center from a Swiss perspective.

One of the main subjects is the importance of multidisciplinary collaboration in bariatric care. Swiss bariatric centers must emphasize the integration of various medical specialties, including surgeons, dietitians, psychologists, and endocrinologists, to provide comprehensive care that meets the needs of patients. This approach aligns with international best practices and ensures that patients receive holistic care addressing both physical and psychological aspects of obesity.

Organizing a bariatric center in Switzerland must prioritize patient-centered care. The Swiss healthcare system's emphasis on patient choice and shared decision-making underscores the importance of tailoring treatment plans to individual patient needs and preferences [21]. This approach can enhance patient satisfaction and long-term outcomes.

Compliance with Swiss healthcare regulations, including those set forth by the Federal Office of Public Health (FOPH), is essential for the successful operation of a bariatric center in Switzerland. Adherence to guidelines, safety protocols, and quality standards ensures patient safety and builds trust within the healthcare system.

Bariatric centers in Switzerland should also serve as hubs for research and innovation. Collaborations with academic institutions and participation in clinical trials contribute to advancing the field of bariatric surgery and improving patient outcomes.

Continuous quality assurance and improvement processes are vital to maintaining the high standard of care expected in Switzerland. Regular audits, outcome assessments, and benchmarking against international standards are essential elements of a successful bariatric center [23].

Discussion

Organizing a bariatric center in Switzerland requires a comprehensive understanding of the country's healthcare ecosystem, regulatory framework and cultural factors. This discussion elaborates on some of the key points raised in the paper and offers insights into the challenges and opportunities associated with organizing a bariatric center regarding the particularities of Switzerland, which of course differ from other regions.

Ensuring equitable access to bariatric care is a challenge in Switzerland's decentralized healthcare system. Strategies such as regional outreach clinics and telemedicine can help bridge the gap and provide care to underserved populations. The offer of bariatric surgery services needs to increase with the aim of increasing the rates of eligible obese patients treated with bariatric surgery in Switzerland the. This counterbalances the drive for high volume centers. To guarantee high quality of provided healthcare, estabilishing benchmarks hence is crucial [17].

The Swiss healthcare system relies on mandatory health insuranceand the coverage of bariatric surgery can vary between insurance companies. As a result, advocacy efforts may be necessary to promote consistent coverage and reduce financial barriers for patients seeking bariatric treatment.

Given Switzerland's central location in Europe, opportunities for collaboration with neighboring countries can facilitate knowledge exchange and harmonization of bariatric care practices in the future. FurthermoreEnsuring long-term follow-up of bariatric surgery patients is crucial for monitoring outcomes and addressing complications. Developing effective post-operative care pathways and patient engagement strategies is an ongoing challenge.

Last, the importance of communication between various healthcare professionals needs to be addressed. The multidisciplinary character of obesity treatment and the involvement of a big variety of professionals mandates clear flow charts for diagnostic and treatment. Processes have to be discussed with all implicated players. Interinstitutional communication is crucial in the process of building up a bariatric center to have functional processes. Moreover, communication by lectures, social media and private talks is also key to get the awareness of referral doctors and reach affected patients which may benefit from bariatric treatment.

In conclusion, organizing a bariatric center in Switzerland is a multifaceted endeavor that requires a deep understanding of the Swiss healthcare landscape, regulatory requirements, and the commitment to providing patient-centered, multidisciplinary care. While challenges exist, the potential for positive patient outcomes and contributions to the advancement of bariatric surgery make this a worthwhile endeavor within Switzerland's high-quality healthcare system.

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