2015 Application for Certificate of Acknowledgement of
Satisfactory Training in Bariatric Surgery
Application Deadline: August 1, 2015
A. Basic Information
Applicant Name
Address
Telephone
Email
Fellowship Program
Academic Year
Institution Name
Program Director
Address
Telephone
Email
Date of Last Accreditation by Fellowship Council
Duration of Accreditation from Fellowship Council
B. Clinical & Technical Experience
Required
Minimum
Number
Total Number of Clinical Fellows in the Program
*Quarterly M & M, including quality improvement & peri-operative management
conferences
Patient Preoperative Evaluations
Postoperative in-patient management encounters
Postoperative out-patient evaluations
Support Group Meetings attended
Patient Educational Seminar
Intestinal bypass operations (Roux-en-Y Gastric Bypass or Biliopancreatic
Diversion +/- Duodenal Switch
Restrictive Cases Performed (Sleeve Gastrectomy and/or Adjustable Gastric
Banding procedures)
Total Number of Bariatric Cases as Primary Surgeon
Revisional Procedures
Total Number of Bariatric Surgeries
Applicant’s
Reported
Numbers
4 per year
50
100
100
1
1
50
10
51
5
100
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C. Research and Publications
Abstract title submitted during Fellowship (one title is required)
Society Submitted
Date Completed
Clinical and/or Research Manuscript or Research Project Poster title completed during Fellowship
(one title is required)
Society Submitted
Date Completed
D. Cognitive and Didactic Requirements
It is mandatory that the Fellow attend at least one session of each of the following topics with at least one
mentor. Opportunities for didactic interactions include specially designated bariatric textbook review
sessions, journal clubs, peer-review conferences, and resident teaching rounds.
1. Epidemiology of Obesity
2. History of Bariatric Surgery
3. Physiology and Interactive Mechanisms in
Morbid Obesity
4. Preoperative Evaluation of the Bariatric Patient
5. Psychology of the Morbidly Obese Patient
6. Essentials of a Bariatric Program
7. Postoperative Management of the Bariatric
Patient
8. Laparoscopic versus Open
9. Laparoscopic Adjustable Banding
10. Other Restrictive Operations
11. Gastric Bypass
12. Biliopancreatic Diversion/Duodenal Switch
13. Revisional Weight Loss Surgery
14. Managing Postoperative Complications
15. Nutritional Deficiencies
16. Obesity in Childhood and Adolescence
17. Outcomes of Bariatric Surgery
18. Role of Endoscopy in Bariatric Surgery
E. Other Required Documents
1.
2.
3.
4.
Applicant’s Curriculum Vitae
Summary of Fellowship Council Case Logs
Patient Evaluation Case Logs
Educational Curriculum of the Fellowship Program
Signature of the Program Director
Date
By signing this form, the Program Director verifies that the Fellow has completed all necessary
Fellowship Council requirements, including the Core Curriculum for ASMBS Fellowship Training.
Please submit the completed application form and all accompanying documentation
electronically, in a single PDF document, by August 1, 2015, to [email protected]. Applicants will
receive an electronic confirmation within 48 hours of submission. If you do not receive this email
confirmation, please call the ASMBS office at 352-331-4900.
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