Weight a Minute!
Abstract & Commentary
By Barbara A. Phillips, MD, MSPH, Professor of Medicine, University of Kentucky; Director, Sleep Disorders Center, Samaritan Hospital, Lexington. Dr. Phillips serves on the speaker’s bureau of Cephalon, Boehringer Ingelheim, Merck, ResMed, and GlaxoSmithKline, and is a consultant for Boehringer Ingelheim, Wyeth-Ayerst, and ResMed.
Synopsis: Death rates in the year after bariatric surgery were high (4.6%), and were higher for men, for those older than 65, and for those whose surgeon performed fewer than 35 such operations a year.
Source: Flum DR, et al. Early mortality among Medicare beneficiaries undergoing bariatric procedures. JAMA. 2005;294:1903-1908.
This study was a retrospective look at death rates for 16,155 Medicare patients who underwent bariatric surgery. Data were collected for those individuals who had claims between 1996 and 2002 for 5 different Current Procedural Terminology (CPT) codes that relate to bariatric procedures. Unique Physician Identification Numbers (PINs) for surgeons were used to calculate the "surgical volume" of each surgeon. Death rates were available from the Medicare Enrollment Database, and were adjusted for comorbidities.
Most (75.8%) of the patients were women, and the mean age was 47.7 years (90% were younger than age 65). Death rates at 30 days, 90 days, and one year were 2.0%, 2.8%, and 4.6%, respectively. Mortality rates at all periods were higher for men, for patients older than age 65, and for those whose surgeons performed fewer than 35 procedures a year (which was the median volume for surgeon). At least part of the reason that older patients were more likely to die was that more of them had procedures done by surgeons who performed an average of fewer than 15 operations per year. The number of procedures done annually more than tripled between 1997 and 2002.
In the same issue of JAMA as the paper by Flum et al, there were 2 other reports about outcomes for bariatric surgery. In an analysis of data from the Nationwide Inpatient Sample, Santry et al confirmed that the number of bariatric surgical procedures in this country is skyrocketing.1 These authors also observed that the vast majority (80%) of bariatric surgical procedures are gastric bypass operations and that women account for the majority (84% in 2002) of those who undergo such surgeries. The good news is that in Santry’s population, hospital length of stay for bariatric procedures fell from 4.5 days in 1998 to 3.3 days in 2002. While in-hospital mortality rates in this study were low (0.1-0.2%), rates of unexpected reoperations for surgical complications ranged from 4-7%. Not surprisingly, the authors noted that those with private insurance and those from "wealthier" zip codes were more likely to have bariatric surgery. In yet a third report on the phenomenon of bariatric surgery, Zingmond et al2 analyzed the hospitalization database for the state of California, and noted that hospitalization rates for 60,077 patients who had Roux-en-Y gastric bypasses went from 7.9% in the year prior to surgery to 19.3% in the year after surgery; in a subset who were followed for 3 years, hospitalization rates 20.2% 19.4%, and 14.9% for first, second and third years after surgery, compared with 8.4% for the year before. About half of the readmission in the first postoperative year were ere for endoscopy, gastric revision, ventral hernia repair, wound infection, small bowel obstruction, or hypovolemia.
Commentary
My office is filled these days with folks who have lifelong, intractable weight problems. Many of these patients are thinking about gastric reduction surgery, and they are asking hard questions. This trio of JAMA papers about bariatric surgery was widely publicized in the lay press, including the Wall Street Journal,3 which noted that the mean age of 47.7 years for the study’s Medicare patients underscores that "severely obese people may be so disabled that they qualify for Medicare benefits." The health consequences of morbid obesity are extensive and extreme, and are well known to all of us. The dismal rates of weight loss with good old diet and exercise are also well known to us (and to our patients in the morbidly obese category, who generally have tried multiple approaches to address the problem). Our hospital has a bariatric surgical program, and I have now begun to see patients who have spent lifetimes battling obesity and its consequences return after bariatric surgery to turn in their CPAP machines and stop or reduce antihypertensive and diabetic medications. Many also have remarkable improvements outlook, and antidepressants may also sometimes be discontinued. My skepticism about bariatric surgery has gradually been replaced by a grudging recognition that it may be the single most effective intervention for the physical and mental well-being of the morbidly obese individual. However, as evidenced by this group of reports, patients who undergo bariatric surgery are very sick folks. They are, as one of my surgical colleagues used to say, "high risk for a haircut." And while they are conspicuous consumers of health care resources prior to surgery, costs may actually go up for the first few years afterward. As these papers point out, it remains to be seen whether gastric reduction surgery will actually save lives or dollars.
So, what do we tell our morbidly obese patients when they ask what we think about weight loss surgery? First, it is probably too early to tell what the long-term results, including complications and weight loss maintenance truly are. Second, the surgeon and his/her experience, especially volume, is critical. Third, the surgery is not risk-free; complications, repeat hospitalization, and death are definite possibilities. Bariatric surgery is truly a last resort.
References
1. Santry HP, et al. Trends in bariatric surgical procedures. JAMA. 2005;294:1909-1917.
2. Zingmond DS, et al. Hospitalization before and after gastric bypass surgery. JAMA. 2005;294:1918-1924.
3. Rundel RL, Spencer J. Concerns grow over weight-loss surgery. Wall Street Journal. 2005;Wed Oct 10, 2005, page D1.
Death rates in the year after bariatric surgery were high (4.6%), and were higher for men, for those older than 65, and for those whose surgeon performed fewer than 35 such operations a year.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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