Tuesday, June 7, 2011

Going for gastric bypass surgery

We were discussing gastric bypass surgery around the dinner table the other day.  That's what happens in medical families.

As always, no names or specifics were mentioned, but the patient in question had gone to Detroit for gastric bypass surgery.  After losing 100lb, she had reached the target weight recommended by her treating physician, and now she was interested in cosmetic surgery to deal with her sagging skin.

The problem is that she is still obese.  Her body mass index (BMI) is over 30.  I have no idea how tall this lady is, but if, for example, her height is 5' 5", this means her weight would be around 180lb.

I know BMI isn't everything.  But it is a quick and easy measurement, especially when you use an online calculator.  A normal BMI lies between 18.5 and 24.9.    The hypothetical 5' 5" lady above would have to need to lose another 30lb to reach the upper end of the normal range.

There is quite a bit of evidence in the surgical literature that points to higher patient complication rates when surgery is performed on people with higher BMI ratios.   The more fat you have, the harder it is for your incisions to heal properly. 

There are also papers that try to justify surgery in such patients, but in my opinion, there is a reason why some cosmetic surgeons with high overheads operate on just about anybody with the cash to pay for a procedure, and sometimes the real risks are conveniently forgotten.  Even otherwise smart people can easily allow the prospect of financial gain to cloud their judgement. 

Necessary surgery is one thing, but when it comes to elective surgery, there's a valid case to be made for carefully screening patients whose weight predisposes them to post-surgical complications.  If money was no object, would you sign up for a breast lift, for example, if you were told the probability of losing a nipple (or worse) was in the region of 10%?  What if the risk was 1%?  Where would your threshold lie?  I'm not saying anybody can accurately quantify these risks.  There are many variables involved, but often times, elective surgery is sold to patients as being virtually risk free.

In my opinion, the story is more complex when it comes to gastric bypass surgery and the subsequent surgeries to remove the sagging skin left behind (Many people are surprised when they learn that while OHIP may cover gastric bypass surgery, a subsequent tummy tuck - costing in the region of $10,000, is not covered).

A severely obese patient who reaches his or her stated target weight by losing 100 lb and  is still technically obese, or at the very least, severely overweight, has not received what they think they signed up for.  It's a horrendously expensive surgery that doesn't address the underlying cause of the obesity.

I have heard plenty of anecdotes of people who underwent gastric bypass surgery and who gained back all the weight they lost.   That's what happens when you don't get to the root of the problem.

Behaviour modification is a big part of the post-surgical treatment of gastric bypass patients, and rightly so.  But you have to wonder how effective it could possibly be when patients are told to eat the "balanced diet" recommended by nutritional bodies that tell us it's ok to eat sugar, and important to eat grains and carbohydrates with every meal.

When this advice results in limited weight loss, it sets patients up for disappointment and failure.  It certainly doesn't eliminate the risks of cardiovascular disease and type II diabetes that accompany clinical obesity.

If behaviour modification can be shown to be effective to bring the patient to a normal weight range, then why not skip the risky surgery altogether, and move straight on to the nutritional part?

If I were considering undergoing this surgery, I would ask a lot of hard questions about the risks.  At the very least, I would want to ask the surgeon what percentage of his or her patients reach a BMI of 25 or lower within 2 years of their surgery, and how many of them are still like that after 5 or 10 years.

I would also want to know about the eating plan and how carbohydrates and sugars fit in their recommendations.

I'll bet the true success rate is a lot lower than prospective patients would like to think.

Those of us who have no intention of going under the knife ourselves are footing massive  provincial hospital insurance bills for this surgery through our taxes.  I shudder to think how much money is being transferred to surgeons and hospital facilities, while the desperate patients don't get the results they have every right to expect.

It all boils down to having realistic expectations.  And from what I can tell, all too often, those expectations don't match up with the reality of gastric bypass surgery.  There are simply too many dollar signs standing in the way of the truth.

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