There are numerous types of endoscopy facilities, including hospital endoscopy units, single- or multispecialty ambulatory surgery centers (ASCs), and office endoscopy suites. Each model has its unique set of advantages, disadvantages, and regulatory issues. The hospital and ASC environments are highly regulated by state and federal agencies and by third party accreditation bodies. In the United States, these include the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the Accreditation Association for Ambulatory Healthcare (AAAHC), and the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF). Private payers sometimes impose their own specific requirements. Office endoscopy suites, previously less regulated, have been subjected to more controls by state and federal agencies in recent years.

The institutional needs of a bariatric program extend across outpatient and inpatient environments. The American Society for Metabolic and Bariatric Surgery (ASMBS) has established a Bariatric Surgery Centers of Excellence program. Education and guidance documents are managed by the independent Surgical Review Corporation (SRC). The Bariatric Surgery Review Committee (BSRC) reviews the information, determines whether the guidelines are met, and grants or denies the designation. Many of these principles may be applied to endoscopy units serving the needs of bariatric patients and in particular for units being developed to perform emerging endoluminal bariatric procedures. Provisional status requires evidence of an institutional commitment to excellence in the care of bariatric patients as demonstrated by infrastructure investment and ongoing in-service education programs in the management of bariatric patients.

Hospitals with established bariatric surgery programs are expected to have these provisions in place, at least within dedicated auspices. When performing endoscopic procedures on hospitalized bariatric procedures, it is desirable to make use of existing provisions. This may mean doing endoscopic procedures in specially designed operating room space. This may prove most meaningful in acutely ill and immediate postoperative patients as well as super-obese patients. For the latter group, facilities and staff dedicated to their management may prove necessary. In most other circumstances, existing endoscopic facilities should be modified and new facilities developed to accommodate bariatric patients at least within a component of their functionality. That said, certain procedures may be resource taxing to the degree that these cases would preferentially be shifted to a designated procedure staging area—be that a hospital operating room, hospital-based endoscopy unit, or ambulatory endoscopy center.

Endoscopy units tending to bariatric patients should be expected to maintain a full line of equipment and instruments for the care of bariatric patients including furniture, wheelchairs, lifts, procedure tables, floor-mounted or floor-supported toilets, beds, radiologic capabilities, surgical instruments, and other facilities suitable for morbidly obese patients [2].

Most programs currently do not have dedicated endoscopy units for bariatric patients. In the past, the occasional severely obese patient was handled on an ad hoc basis with existing equipment. Endoscopy programs need to have access to equipment and instruments for the care of patients who undergo bariatric surgery, which may include bariatric accessories (e.g., clips, stents, fibrin glue), and fluoroscopy to accommodate obese and super-obese patients. Radiology equipment with a weight capacity of more than 450 lb (200 kg) has only recently become available. Furniture and equipment should be able to accommodate patients that are within the anticipated patient weight limits established by the program. Weight capacities should be documented by the manufacturer’s specifications, and this information should be available to relevant staff [3].

In accordance with provisional status designation by the SRC, appropriate patient movement/transfer systems must also be located wherever bariatric surgery patients receive care. Personnel must be trained to use the equipment and, most importantly, capable of moving these individuals without injury to the patient or themselves. That said, hospital-based and ambulatory endoscopy units do not need to change all of the equipment, furniture, and instruments throughout the entire facility. This requirement only applies to those areas where patients undergoing bariatric surgery receive care. For some programs, then, this is a dedicated bariatric patient care area. Endoscopic outcomes may well be enhanced when conducted by endoscopists and in endoscopy units with a particular interest, investment, and higher volume of bariatric and related endoscopy.

The remainder of this chapter will address specific requirements and recommendations for all relevant areas in the endoscopy unit.

Because severely obese people have generally been stigmatized by society, they are often reluctant to venture out of their homes and comfort zones. There are many factors for consideration in the shaping of a space to accommodate severely obese patients—some patently evident and others that are less obvious. It is important to have furniture, clothing, doorways, bathrooms, and wheelchairs that are appropriate and comfortable for patients with morbid and supermorbid obesity and their families. Families of obese patients tend to be large-sized also, and so accommodations for accompanying family members must also be considered (Fig. 23.1).