Obesity surgery: A costly ‘after’

The before-and-after pictures are striking and seductive, and Americans love a quick fix almost as much as they love a heaping buffet. As a result, the United States has seen explosive growth in the popularity of bariatric surgery.

The procedures, which reshape the gastrointestinal tract to limit a patient’s intake and absorption of calories, have jumped from some 13,000 in 1998 to a predicted 170,000 this year. And that, say physicians who perform the surgery, may be less than 1% of those who could benefit from the operation.

But for all the inspirational stories of lives transformed -- and a growing parade of celebrity testimonials (Randy Jackson, Sharon Osbourne, Roseanne Barr, opera star Deborah Voigt) -- weight-loss surgery is serious stuff, with the price tag and medical risks to show for it. A flurry of recent studies has been a sobering reminder of that.

Men, patients older than 45, and those with hypertension are more likely to die after bariatric surgery than earlier studies had shown. Elderly patients benefit least and are twice as likely to die after bariatric surgery than those who get hip replacements and surgery to replace or repair coronary arteries. Obese patients given to “emotional eating” have lower rates of success after the surgery. And, in some patients, vitamin A deficiencies are showing up years down the road.

Now, the Agency for Healthcare Research and Quality -- an arm of the federal government’s public health service -- has revealed that, in 2001-2002, about four in 10 bariatric surgery patients experienced significant complications in the 180 days after their operation. Although the overall death rate among these patients was low, 7.2% of the 2,522 patients studied had to be readmitted to the hospital within 180 days after surgery.

Collectively, the studies could temper enthusiasm for a weight-loss solution undergoing rapid change as well as explosive growth. They also may significantly slow the decisions of states and private insurers to cover the costs of weight-loss surgery. At the same time, the studies are being forcefully countered by bariatric surgeons, who assert that their fast-moving profession has left many identified problems behind.

The new study shows that postoperative complications pushed costs for bariatric surgery upward considerably. For those who experienced a complication, average costs climbed from $25,337 per patient to $36,542. For those who were readmitted to the hospital for complications, the total bill averaged $65,031.

“This study shows how important it is for patients to consider the potential complications” of bariatric surgery, said Dr. Carolyn M. Clancy, director of the Agency for Healthcare Research and Quality.

Those cost numbers, released last week, are likely to be of particular interest to the federal agency that oversees Medicare, which in February agreed to cover bariatric surgery for certain patients under the age of 60. Medicare also requires that surgery be performed in surgical centers and by physicians accredited in the procedures. Coverage of bariatric surgery for those on Medicaid (Medi-Cal in California) varies from state to state, and many states are considering whether and under what conditions to cover such operations. Since 1989, Medi-Cal has paid for such surgery for patients over 21 with a doctor’s recommendation.

Most common -- 20% of those with complications -- were patients with evidence of “dumping syndrome,” in which undigested food is moved too quickly into the small intestine, causing vomiting, reflux and diarrhea. But 12% of those with complications suffered leaks or strictures at the site where the stomach and the intestine have been surgically fused, and 7% suffered from abdominal hernias.

The latest study -- and many of those that have come before it -- have elicited strong objections from leaders in the field of bariatric surgery, who have called them outdated, shoddy and unnecessarily alarming.

“I think it’s way dated, and I think it’s very inaccurate,” said Dr. Harvey Sugerman, who chairs a new committee established by the American Society for Bariatric Surgery to accredit centers and surgeons performing the procedures.

During the period studied, Sugerman said, techniques for the surgery required large, open incisions, making postoperative complications far more numerous than with the newer, laparoscopic techniques that now account for most bariatric surgeries. During the same period, more bariatric surgeries were done by physicians who were inadequately trained or who did not perform these operations frequently, he added. Finally, he complained that, by using insurance claims and billing documents to collect its medical data, the government study over-counted, miscounted and mischaracterized many post-operative complaints. For instance, it incorrectly characterized many “teaching opportunities” -- such as reflux, diarrhea and vomiting when a patient eats too much or chooses fatty foods -- as a complication. “Many of us, and patients alike, consider that to be a benefit; it helps them to avoid the bad stuff.” The latest study “gives more ammunition to health insurers to say we shouldn’t cover this,” said Sugerman. It’s “unfortunate because in the right hands, this surgery is lifesaving.”

For those interested in the surgery, the right hands have come to be a critical factor separating patients with poor outcomes from those who avoid complications, lose weight and reduce the health problems caused by obesity, including diabetes, high blood pressure and heart disease.

In the most common procedure, surgeons create a small stomach pouch and attach a section of the small intestine to it, forcing food to bypass the lower stomach and parts of the small intestine. Other procedures place an adjustable band around the stomach or require the removal of part of the stomach.

In a study published July 2005 in the Journal of the American Medical Assn., Dr. David R. Flum of the University of Washington found that patients whose surgeons performed fewer than 20 bariatric surgeries a year were almost five times more likely to die in the month following their operation than those whose surgeons performed the operation more frequently. Postoperative death was also much higher in hospitals that performed fewer than 50 bariatric surgeries a year.

Statistics like these, say bariatric surgeons, have helped drive many surgeons who were not specialists away from doing these procedures, and helped concentrate bariatric surgeries in “centers of excellence” that meet new standards set by the American Society for Bariatric Surgery. Currently, said Sugerman, the ASBS’s Surgical Review Corporation has accredited more than 140 centers and more than 400 surgeons. Another 500 centers and between 600 and 700 surgeons have applied for provisional approval.

Although critical of many of the studies underscoring problems, Duke University researcher and bariatric surgeon Eric DeMaria said the warnings were valid and important, in particular, for patients considering weight-loss surgery.

“You have to be well-informed as a consumer in terms of what level of expertise” you get in your hospital or doctor, said DeMaria. In addition, as bariatric surgery is now being sought by teens and the elderly, surgeons are beginning to recognize which patients will benefit most from surgery and which patients may need to avoid it, lose weight first, or have their weight-loss surgery in stages that lower their risk of complications.

That, said DeMaria, “is part of the maturation of the specialty.”