Gastric Bypass: Let the Morbidly Obese Beware
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Gastric bypass surgery is on the rise, and so too are the rates of hospitalizations and early postoperative deaths related to complications.
So reported researchers in three studies published in the Oct. 19 issue of Journal of the American Medical Association.
“Medical interventions for weight loss do not have such dramatic and persistent weight loss associated with them, making surgical intervention attractive to individuals who have been unable to successfully lose weight,” wrote David S, Zingmond, M.D., Ph.D., and colleagues at the University of California at Los Angeles.
But those interventions—while reducing the frequency of associated conditions such as diabetes, hyperlipidemia, hypertension, and sleep apnea—come at a price.
In a retrospective study of 66,077 California patients who underwent Roux-en-Y gastric bypass surgery from 1995 to 2004, the rate of hospitalization in the year following surgery was more than double that in the year before bypass, Dr. Zingmond and colleagues reported.
Among nearly 25,000 bypass surgery candidates for whom three-year follow-up data were available, a mean of 8.4% were admitted to the hospital a year before surgery, primarily for obesity-related problems such as osteoarthritis, and cellulitis of the lower extremities.
In contrast, 20.2% of patients were hospitalized in the year after surgery, 18.4% in the second year, and 14.9% in the third. Postsurgical hospitalizations tended to be for complications that were likely related to surgery, such as gastric revision and ventral hernia repair, the investigators noted.
A second study of bariatric surgery performed on Medicare beneficiaries found that risk of death within one year of surgery is higher than that suggested by other studies, and that among patients 65 and older the risk of early death is nearly three times greater than that of younger patients.
David. R. Flum, M.D., M.P.H., and colleagues at the University of Washington in Seattle took a retrospective look at data on 16,155 patients (mean age 47.7 years) who underwent bariatric surgery.
They found that in contrast to other series, which suggested a perioperative death rate of about 0.5%, the rates of 30-day, 90-day, and one-year mortality were 2.0%, 2.8%, and 4.6%, respectively. At every time point, men were about twice as likely to die as women (3.7% vs 1.5%, at 30 days, 4.8% vs 2.1%, at 90 days, and 7.5% vs 3.7% at one year, P<0.001).
In addition, patients older than 65 had at about a threefold greater risk for early death than younger patients (4.8% vs 1.7% at 30 days, 6.9% vs 2.3% at 90 days, and 11.1% vs 3.9% at 1 year; P<0.001). Among patients 75 and older, after adjustment for sex and comorbidity index, the odds of death within 90 days were fivefold higher than those of patients ages 65 to 74 (odds ratio, 5.0; 95% confidence interval, 3.1-8.0).
Dr. Flum and colleagues also found that less-experienced bariatric surgeons had more unfavorable outcomes. Patients who were operated on by surgeons with less than half of the median surgical volume of bariatric procedures had an odds ratio for death at 90 days of 1.6 (95% CI, 1.3-2.0) compared with patients of higher volume surgeons.
“Those considering the role of bariatric procedures in older patients should balance this population-level risk of adverse outcomes against the anticipated benefits of the procedure,” the investigators wrote. “Directing care of older patients to surgeons who perform higher volume of bariatric procedures in Medicare beneficiaries might be expected to improve outcomes in this high-risk population.”
The third study looked at trends in bariatric surgical procedures nationwide, and found an increase from an estimated 13,365 in 1998 to 72,177 in 2002. There were upward trends among women, people ages 50 to 64 years, privately insured patients, and those from wealthier communities.
Over the study period, the average length of stay for bariatric surgery decreased by slightly more than a day, while complication rates remained unchanged, reported Heena P. Santry, M.D., and colleagues from the University Of Chicago and University of California at Irvine.
“Although preventing obesity should remain the focus of U.S. health care, efforts must be made to ensure equal access to bariatric surgery irrespective of sex and socioeconomic status for those who are morbidly obese, have an indication for surgical intervention, and wish to undergo an elective surgical procedure to improve health, longevity, and quality of life,” Dr. Santry and colleagues wrote.
“These studies demonstrate that there are vulnerable patient populations and potential additional costs associated with surgery but suggest that surgical volume helps mitigate these risks and costs,” wrote Bruce M. Wolfe, M.D., of Oregon Health & Sciences University in Portland and John M. Morton, M.D., M.P.H., of Stanford in an accompanying editorial.
“Bariatric surgery may be a potentially life-saving intervention in the right patients and in the right surgeons’ hands,” they added. “The studies presented in this issue indicate that experience and technique count.”
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