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Experts Debate Safety of Various Weight-Loss Surgeries While Lawmaker Urges Strict Oversight of Obesity Surgery Programs

Jan 3, 2006 | Overweight Americans now have several surgical options to help them lose weight, including gastric bypass surgery, adjustable stomach bands, and an operation which removes part of the stomach and reroutes the intestines. Doctors, however, are divided on what is the safest and most effective procedure.

Gastric bypass, in which the stomach is stapled to reduce its size, is currently the most frequently performed weight loss surgery in America. It is effective in facilitating the rapid loss of a large amount of weight and is used to treat people with heart problems and diabetes caused by obesity.

In Europe and Australia, adjustable stomach bands are preferred over gastric bypass. In this type of surgery, a ring is placed over the top of the stomach and inflated with saline to tighten it and restrict how much food can enter and pass through the stomach.

This reversible procedure is safer, with a 0.1% death rate compared to about 2% for gastric bypass. Long-term it is nearly as effective at helping patients lose weight. It is also the recommended procedure for children or women who may want to get pregnant after surgery.

According to the research of Dr. Paul O'Brien, director of the Centre for Obesity Research and Education at Monash University in Melbourne, Australia, the bands are just as successful as gastric bypass for achieving weight loss over an extended period.

O’Brien considered results on 23,638 patients in 43 published studies to determine that although bypasses induced a greater weight loss in the first three years, bands were comparable after seven years, with 55% (bypass) and 51% (bands) of excess weight lost.

The third, and by far the most risky, option is a surgical procedure that removes three-quarters of the stomach to create a banana-shaped organ that is connected to the small intestine. This surgery bypasses more of the small intestine than a regular gastric bypass does. Although the mortality rate can be as high as 5%, the procedure is becoming more common and now represents 5% of U.S. obesity surgeries.

While a large U.S. government study has begun to evaluate the benefits and risks of the three procedures, studies indicate that no surgery will have a significant impact without the patient’s commitment to a healthy diet and exercise routine.

Overweight patients should not undergo any surgical procedure unless other methods of weight loss have proved unsuccessful. To qualify for the surgery they must also be at least 100 pounds overweight, or have a Body Mass Index over 35 as well as diabetes or high blood pressure.
Increasingly, many people fall into these categories and the numbers of surgeries have risen dramatically. Whereas less than ten years ago, fewer than 10,000 surgeries were done in the United States, in 2005 it is estimated there will be more than 170,000 according to the American Society for Bariatric Surgery.

In the future there will be more options for obese Americans trying to lose weight. These include vagus nerve stimulation, to curb the desire for food, and new drugs such as rimonabant that shuts off a pleasure signal in the brain that triggers people to eat.

In a related story, a investigative report by the Boston Globe has prompted Massachusetts Senator Richard T. Moore to call for an investigation of mortality and complication rates for obesity surgery at hospitals that fail to meet existing safety guidelines in that state.

A comprehensive report by the Boston Globe found that, even though they fail to meet voluntary patient-safety guidelines, at least five Massachusetts hospitals continue to perform obesity surgery.

But starting in 2007, Blue Cross and Blue Shield of Massachusetts, the state's largest health insurer, will no longer pay for the procedure at hospitals that do not meet these and other standards.

In the wake of a highly publicized patient death, the state-appointed committee of health officials urged (in August 2004) that the medical community in Massachusetts adopt strict standards for gastric bypasses and other popular obesity surgeries.

The committee offered several suggestions to hospitals, one being that they handle more than 100 cases per year, and that individual surgeons perform a minimum of 50 operations per year.

The Globe surveyed hospitals that did not meet this volume standard in 2004 and found that at least five hospitals still perform obesity surgery, even though they treat fewer patients than recommended by the committee: Caritas St. Elizabeth's Medical Center in Boston, Morton Hospital in Taunton, Beverly Hospital, Tobey Hospital in Wareham, and Winchester Hospital.

Although the hospitals did between seven and 70 of the surgeries during the fiscal year that ended Sept. 30, 2005, they defended their programs.  Several said they expect to exceed 100 cases by the time the Blue Cross payment policy takes effect in 2007.

The panel had other recommendations for hospitals and doctors, including how to train surgeons, the level of hospital staff expertise, and how to select patients. The Globe did not ask hospitals whether they comply with these recommendations, however.

According to state officials, 22 Massachusetts hospitals performed 3,040 obesity surgeries in the fiscal year that ended Sept. 30, 2004.  Just 402 obesity operations were performed in 1998.

On average, obesity surgery carries a 1% risk of death and a 1% to 15% risk of complications, according to the panel. A recent study found that the risk of death is elevated for the elderly: 2% within 30 days of surgery and 4.6% within a year.

Blue Cross spent $20.5 million to cover obesity surgery for 1,214 members in the year ended June 2004. Executives at Blue Cross believe that the surgery should be done only at hospitals that demonstrate high-quality care and a good performance record.

"We know there is a significant variability in care across Massachusetts," said Dr. John Fallon, Blue Cross's chief physician executive and a member of the committee that developed the surgery guidelines.

Hospitals will now receive applications from Blue Cross asking for detailed information on obesity surgery programs. The hospitals will have one year to comply with the panel’s recommendations. Blue Cross and Blue Shield of Massachusetts will stop paying for obesity surgery at hospitals that fall short of these standards starting in January 2007.

Moore wants that date moved up to October 2006, when hospitals begin their fiscal year, and he will request Blue Cross to accelerate its starting date. He also intends to request that the state's other major insurers adopt a similar policy.

According to the  Globe, Moore, co-chairman of the Legislature's Joint Committee on Health Care Financing, requested the investigation in a letter to Paul Cote, Commissioner of the Massachusetts Department of Public Health, asking him ''to take strong corrective action if any of [the hospitals'] patients were harmed in any way as a result of the failure."

Moore said that if any of the low-volume hospitals also fail to meet other safety guidelines, they should be prohibited from performing the surgery. ''This surgery has had a lot of deaths in the past few years; that's why we set up this panel to recommend specific practices."

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