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Gastric-Bypass Surgery Offers Rapid Weight Loss, Risks

Feb 9, 2005 | Scripps Howard News Service

The obesity epidemic, media hype and aggressive hospital marketing have fueled demand for the most drastic weight-loss solution: bariatric surgery.

The number of surgeries performed in 2004 surged to 141,000, according to the American Society for Bariatric Surgery, in Gainesville, Fla.

And, while 170,000 surgeries are expected to take place this year, they represent a fraction of the medical need. An estimated 8 million Americans are morbidly obese more than 100 pounds overweight and could qualify for the surgery.

For many patients, bariatric surgery is a lifeline. It reduces the size of the stomach, and patients shed 1 pound a day until they've lost an average of 100 pounds.

Weight-loss surgery has become a lucrative business for hospitals and surgeons. It carries a price tag of $25,000. The surgery is not typically covered by health plans, meaning patients usually pay for it out of their own pockets.

As the number of surgeries continues to rise, so do deaths and complications. Gastric-bypass surgery, the most common stomach-reducing procedure, kills as many as one in 50 patients, experts say.

Lawyers say they've seen a flood of cases, and medical-malpractice insurers are scrutinizing bariatric surgery, in some cases refusing to write new policies until they can better quantify the surgery's risks.

New York's Medical Liability Mutual Insurance Co., which covers half of New York's doctors, in November imposed a moratorium on the operation. It's the third and final New York carrier to halt coverage for new bariatric surgeons, effectively limiting the market.

Increased risk management doesn't mean patients won't have access to the surgery. Rather, it's a wake-up call to doctors and hospitals: Improve your program or leave the business.

That should benefit patients in the long run. There's also a movement afoot to designate a special class of top-notch bariatric programs and physicians. Those hospitals would receive a seal of approval from the Raleigh, N.C.-based Surgical Review Corp., much like credentialed trauma and transplant programs, for implementing extensive safety measures and employing only experienced surgeons.

From 1999 to 2000, an estimated 64 percent of U.S. adults were overweight or obese, which is more than 20 percent overweight, according to the Centers for Disease Control and Prevention.

Obesity goes beyond health.

Worse, after a person becomes more than 100 pounds overweight, diets often don't work, said expert bariatric surgeon Dr. Henry Buchwald of the University of Minnesota.

That fuels the popularity of bariatric surgery, which appears to be one of the few remaining solutions to a drastic problem.

Although the surgery's most visible effect is weight loss, the effects are more profound. Morbid obesity can lead to diabetes, heart disease, sleep apnea, high cholesterol, hypertension and joint pain. Weight loss cures the diseases.

"You have a patient who walks into your office with a problem," said Dr. Jonathan Schoen, a bariatric surgeon at the University of Colorado, "and their problem isn't going to kill them today, or tomorrow or necessarily next year, but it is going to kill them."

Julie Svoboda, who gained weight in her teens, due to polycystic ovary syndrome, was desperate for the surgery, which she had last November.

She likened the risks to a shoulder surgery she had.

"It's the same risks. You're going under," she said. "There's blood clots for both; if it was my time, it was my time."

Eighty-five percent of surgeries are gastric bypasses. The surgeon creates a 2-inch-long pouch at the top of the stomach and then attaches a portion of small intestine. After surgery, patients can eat only a small amount of food, and it passes quickly through the stomach and digestive tract meaning fewer calories are absorbed.

The most common complication occurs when a staple fails, causing the stomach's contents to leak. The resulting infection can quickly turn fatal.

Studies show that in the two months after surgery, one in 20 patients will suffer significant complications, and one in 10 will suffer a minor complication.

Deaths are more difficult to quantify. Experts' estimates of deaths from the surgery range from one in 200 to one in 50.

Dr. David Flum, an assistant professor at the University of Washington in Seattle, followed the long-term survival of 3,000 morbidly obese patients who underwent gastric-bypass surgery.

He found that 1.9 percent died within 30 days of the surgery. And patients who went to surgeons who had performed 20 or fewer surgeries were five times more likely to die.

Buchwald takes a different tack. His research found mortality rates of one in 200 for gastric-bypass surgery.

"The risk of obesity surgery is no higher, and probably lower, than the risk of any other major surgery," he said. "We don't have these questions being asked about breast cancer, or heart attacks, or colon cancer."

The Physician Insurers Association of America notes a slight increase in the number of bariatric-surgery malpractice claims, up to 21 in 2003 from 10 in 2000.

But lawyers say that doesn't reflect the recent surge in lawsuits because of the lag between surgery, claim and a court date or settlement.

If the surgery for bariatric patients is complex, so are their pre- and postoperative needs. Morbidly obese patients require expensive equipment and special staff training.

In response to an alarming rise in complications, a movement is gaining steam to designate "Centers of Excellence" in bariatric surgery. To date, 200 institutions have applied.

"It points out that these are very difficult and vulnerable patients, and the surgery is technically demanding, and the care is demanding," said Dr. Walter Pories, president of Surgical Review Corp., the nonprofit credentialing organization.