Friday, April 09, 2004

Bariatric surgery taking on the chin from multiple sides. First off from MSNBC: Gastric bypass riskier than many patients know

In 1991 Diana Nejbauer hit 261 pounds and was thrilled to undergo surgery to reduce the size of her stomach. But the procedure didn't work. "I was sick from the very beginning," says Nejbauer.
Not only did she vomit constantly, but her weight, which fell initially, started climbing back up to where it had been. "It was devastating. I couldn't believe it," she adds......Catherine Bast's husband Dave died from complications of his weight-loss surgery. "We would have never went through it knowing all the risks," she says.
No one knows the complication rate from obesity surgery because there is no national registry to track it. Estimates of the death rate alone are as high as 2 percent.

Buyer's remorse with appliances and automobiles is one thing, with surgical procedures it is something else entirely. I wonder if Ms. Bast's husband's informed consent did not mention death, or did he sign it without reading it The fourth paragraph of the informed consent papers used at the Acme Surgical Corp reads as follows:

As a result of this procedure being performed there may be material risks of: INFECTION, ALLERGIC REACTION, DISFIGURING OR PAINFUL SCAR, BLOOD CLOTS OR PULMONARY EMBOLI, SEVERE LOSS OF BLOOD, LOSS OR LOSS OF FUNCTION OF ANY LIMB OR ORGAN, PARALYSIS, PARAPLEGIA, QUADRIPLEGIA, BRAIN DAMAGE, CARDIAC ARREST OR DEATH. Loss of blood may require transfusion of blood or blood products which carries a risk of exposure to viral hepatitis and AIDS.

Pretty clear to me. I'm not denying that some paint a rosier picture than others and may gloss over the risks, but saying you "would have never went through it" if you knew the risks begs the question: Why didn't you ask?

Liability carriers are also taking a long, hard look at the risks of bariatric surgery:

To date, MAG Mutual Insurance Company has incurred $3,838,071 for 24 bariatric surgery claims. Most of these claims have been filed in the last two years. Frequent postoperative complications included gastric leakage, blood clots, respiratory compromise and wound infection. Although most of these claims resulted from recognized complications, the allegations which brought the physicians into the cases were usually failure to timely recognize complications and intervene.

And they look at danger areas by providing examples:

A 30-year-old man had a laparoscopic Roux-en-Y procedure at a hospital’s newly opened bariatric surgery clinic. The night after surgery he developed leg pain which was documented in the medical record, but not reported to the attending surgeon. About 6:00 AM he arrested. Resuscitation was successful, but the patient suffered moderate brain damage and is permanently disabled. Physicians and patients are at risk when support staff is inadequately trained.

A 47-year-old hypertensive diabetic woman, weighing 400 lbs underwent laparoscopic adjustable gastric banding. She did well initially, but soon became noncompliant with her dietary restrictions. She developed erosion of the stomach and had to have corrective surgery and subsequent removal of the device. She sued her bariatric surgeon alleging that she was not properly informed and in fact was not a good candidate for surgery. This case illustrates the need for informed consent, extensive informed preoperative screening and psychological evaluation before surgery.

This scenario is similar to what we have faced twice in the past year:

In 1997 a 35-year-old, 325-lb woman flew to a distant city to have an open Roux-en-Y procedure because there were no local surgeons who performed bariatric procedures. The procedure and hospitalization went well, and the patient was released after five days to be followed by her local surgeon. She experienced nausea and vomiting after returning to her home. The local general surgeon treated her with Phenergan which relieved the nausea. She presented to the Emergency Department the next day with low-grade fever and nausea. Again she was treated and sent home. That night she was transported to the Emergency Department in shock. The shock resulted from sepsis and peritonitis caused by a leaking suture line. The patient died. A case was brought against the local surgeon, and the Emergency Department physician who allegedly did not recognize the known complication. This case points out the danger of taking over postoperative care when not familiar with the procedure or its complications.

We have become involved with patients that have had their surgery elsewhere and presented in our town with complications. (We do not perform bariatric surgery at the Acme Surgical Corp.) These patients are difficult to manage for many reasons. The main reason is the complications themselves. Once "fixed" these patients don't want to return to their original surgeon and we inherit them. Often these patients have underlying emotional or psychiatric issues which can make things more problematic. And inevitably litigation is involved. Few things rankle a surgeon like having to take care of another surgeon's complications. Another Piece of Resident Wisdom that has been ingrained in me is sometimes known as "Frankenstein's Rule":

You create the monster, you live with the monster

Well moving on, some medical insurers are cutting back on bariatric coverage:
Insurers trim bariatric surgery coverage

As America grows fatter, some insurers' coverage of weight-loss surgery is becoming leaner.

BlueCross BlueShield plans in Florida and Nebraska are among those who recently announced they no longer would cover gastric bypass surgery. CIGNA Corp. has stopped coverage in four states and is looking to withdraw coverage in more states as contracts expire.

It's not just bariatric surgery being targeted. According to the Center for Studying Health System Change, insurers, under pressure from employers, are increasingly looking at eliminating coverage for procedures perceived as high-cost and unnecessary.

But bariatric surgery is a particularly high-profile and popular procedure. Nationwide, the estimated number of gastric bypass surgeries -- touted by celebrities such as singer Carnie Wilson, TV personality Al Roker and "American Idol" judge Randy Jackson -- climbed more than 500% between 1993 and 2003, from 16,800 operations to more than 103,000, says the American Society for Bariatric Surgery. This comes as the proportion of Americans with a body mass index of 40 or more -- at least 100 pounds overweight -- increased fourfold between 1986 and 2000, from one in 200 to one in 50. Insurers that pay for the surgery typically require a BMI of 40 or more for coverage, or 35 for patients with serious comorbid conditions.

But firms cutting coverage say they can't afford to keep paying for what they see as risky surgery, with a reported death rate of three out of 1,000 procedures, that is increasingly being done by less-qualified doctors.

The insurance companies are arguing the exclusion on economic grounds, despite the problems of obesity:

At this point, however, many employers and insurers aren't ready to trade short-term financial pain for possible long-term gain, especially with the likelihood a patient will change employers or plans before they benefit from any future cost or health benefit from the surgery.
Employers "are clearly looking for cost management," said Razia Hashmi, MD, MPH, medical director and vice president for coverage policy with CIGNA, which this year dropped coverage for weight-loss surgery in Arizona, Florida, North Carolina and Texas. A 2003 survey by Mercer Human Resources Consulting found that among companies with more than 500 workers and employer-sponsored health plans, 52% chose not to cover bariatric surgery.

The lack of foreseeable economic benefit, combined with the cost of managing complications due to marginally-trained surgeons have made bariatric surgery less appealing to insurers. This will cause many patients to finance the procedure themselves, as was the case before insurers began to pick up the tab. Bariatric surgery began to attract surgeons for me reason that Willy Sutton robbed banks, because that is where the money was.
But why only bariatric surgery? There are multiple other procedures that have been studied and found to have minimal benefit. Examples include spinal surgery for pain, adhesiolysis for pelvic pain, and knee arthroplasty to name a few. But those operations don't have the high mortality rate that bariatric surgery does and haven't gotten the "bad press" that gastric bypass has. I don't think it is "discrimination against the obese " as some quoted in the above article opine.
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