Bariatric Surgery

If a bariatric procedure needs to be redone, doctors call it a revision. While that seldom happens anymore in operating rooms, the industry itself has undergone a sort of revision in the past several years.

Bariatric surgery has been around in some form since the 1960s. But in those early years, surgeons did whatever they thought would be safe and effective. There were no hard and fast surgical guidelines like there are today, with an accrediting organization like the American Society for Metabolic and Bariatric Surgery (ASMBS)

Now, the safety and efficacy of weight-loss surgery is widely accepted by groups such as the American Heart Association and the American Diabetes Association. The surgery can lead to dramatic weight loss. Some people lose 100 pounds in six to nine months. 

The American Medical Association last year opted to classify obesity as a disease. Obesity affects more than 78 million Americans, according to the U.S. Centers for Disease Control and Prevention (CDC). It can lead to any of 40 other diseases, including diabetes, heart disease, arthritis, stroke, and even cancer. Obesity cost the U.S. economy $198 billion in 2011, according to a report published by the Society of Actuaries.

Research shows that weight-loss surgery can cure type 2 diabetes, dramatically lower the risk of heart disease, and, in theory, save health insurers loads of money. Whether the savings are actually accruing is still up for debate.

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While bariatric surgery is a huge moneymaker and is typically covered by insurance, it won’t be successful if the patient isn’t ready for their new body. The industry has begun to recognize that the procedure is not one-size-fits-all. It has backed off from aggressive billboard marketing campaigns and is being choosier about which patients are approved for the surgery. 

It is major surgery and has about the same mortality rate as gallbladder surgery, Dr. John Morton told Healthline. Morton is chief of bariatric and minimally invasive surgery at the Stanford University's School of Medicine and serves as president-elect of ASMBS.

Not Something to Be Taken Lightly

Obesity is a health problem, and bariatric surgery is at least a short-term cure. But in the heyday of bariatric surgeries about a decade ago, aggressive marketing caused many people to ask about it without thinking things through, Dr. Eraj Basseri told Healthline.

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Basseri is a surgeon at the Khalili Center in Los Angeles. The center performs all three types of bariatric surgery — Lap-Band, sleeve gastrectomy, and gastric bypass.

Lap-Band has traditionally been heavily marketed as a safe, affordable weight loss solution. But it has the highest failure rate of all bariatric surgeries. Gastric bypass, where food is rerouted past a large part of the stomach, tends to be more successful. With Lap-Band in particular, people can “cheat” after the surgery, Basseri said. They can suck down liquids loaded with carbohydrates, such as milkshakes, and they won’t feel full.

The arrival of Lap-Band, which works for many people, seemed to herald a quick-fix for weight loss. Basseri spoke of communities with dueling billboards all over town that screamed “Get your bariatric surgery here!” Surgical centers ended up attracting patients who were uneducated about the surgery and who were not provided with pre- and post-operative care.

“What the billboards did, especially in Los Angeles, was make a serious operation into a one-hour lunch meeting,” Basseri said.

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He said the surgery itself comprises only one part of the goal of losing weight and keeping it off. “If you don’t focus on their psychological aspects, the nurturing and the support, the [patients] won’t succeed,” Basseri said.

To put it bluntly: “They have a messed up relationship with food,” Basseri said. “The relationship with food has to improve. This first year (after the surgery) is the honeymoon phase, as we like to call it, and the relationship with food during that time has to get better.”

Candidates Must Be Mentally Ready

Aggressive ad campaigns were pervasive not only in body- and health-conscious Los Angeles. Even in the mid-sized Quad-Cities, an assortment of bi-state communities straddling the Mississippi River in Iowa and Illinois, hospitals heavily marketed bariatric surgery.

Sara Neyens is nurse manager for the surgical weight loss program at UnityPoint Health-Trinity in Moline, Illinois. She said the program has come a long way since about 10 years ago, when business was booming. She said back then getting the surgery was simple, but there wasn’t much support or education.

“It was obvious to the insurance as well as the medical communities that this was not the way to go,” Neyens told Healthline. “Patients are not successful if they do not have their dietary and mental health needs met, pre- and post-op.”

Now, potential patients are put through extensive counseling and education. Not only do they get a complete physical check up, including cardiovascular and sleep tests, but they receive extensive mental health counseling as well. “It’s stressful on the body, but it’s also stressful mentally,” Neyens said.

“Patients are not successful if they do not have their dietary and mental health needs met, pre- and post-op. It’s stressful on the body, but it’s also stressful mentally.” — Sara Neyens, UnityPoint Health-Trinity hospital.

Trinity requires patients to have a new exercise and diet regimen in place before the surgery will be performed. Anyone weighing more than 400 pounds has to lose weight first with diet and exercise before the hospital will operate.

But psychological support is also necessary as people who have the surgery begin to live a new life. “From time to time, people will make comments even though they don’t mean to be hurtful,” Neyens said. “They’ll say things like, ‘You’re not eating very much. That can’t possibly be healthy. Are you not feeling well?’ And some people get jealous.”

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Are We Saving Money by Living Healthier?

How far do the benefits of the surgery go? It is now well established that the procedure can reverse type 2 diabetes, sometimes even if a patient is still obese. People living with a host of health problems, from cardiovascular disease to arthritis pain, slowly see their need for medications evaporate.

The surgery costs about $30,000, Basseri said. The idea is that if the surgery jumpstarts weight loss and people begin to feel better by looking great, they permanently adopt a healthy lifestyle of exercise and sensible eating.

"When it gets rid of that diabetes it’s not just a couple of hundred [saved] a month for that insulin, but for that amputation that would have happened five years down the line, or pneumonia, or stroke,” Basseri said.

study on the value of bariatric surgery came out in 2010. Published in the journal Diabetes Care, the article concluded that gastric bypass and gastric banding were cost-effective ways to improve outcomes for severely obese people with diabetes. It affirmed that the surgery can reverse type 2 diabetes independent of weight loss.

“When it gets rid of that diabetes it’s not just a couple of hundred [saved] a month for that insulin, but for that amputation that would have happened five years down the line, or pneumonia, or stroke.” — Dr. Eraj Basseri, Khalili Center

It did not find the surgery to be less expensive than medical management, but it also did not factor in cost savings related to other health problems that may have been resolved by the weight loss. “For example, decreasing blood pressure or decreasing the need for joint replacement could definitely reduce costs for surgical patients,” according to a summary published in the Canadian Journal of Surgery.

But the issue of joint replacements is a tricky one when assessing bariatric surgery’s financial impact on the healthcare system. In a study published last year in the Journal of the American Medical Association, Surgery, researchers showed that medical costs remained the same even six years after the surgery.

Morton pointed out one possible reason why. While some people may not need joint replacement once they lose weight, for others it still may be a necessary procedure. Major operations such as joint replacements can’t be performed on unhealthy, obese people. Bariatric surgery sometimes allows other surgeries that had been put off to finally be performed.

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A New Lease on Life at 65

Kathy Maugh had gastric bypass surgery at the age of 65. She never had a weight problem until later in life. It wasn’t so much her weight that bothered her as it was the threat posed by the type 2 diabetes she had developed.

She chose the Khalili Center because they had saved her husband’s life. He had bariatric surgery back in the 1960s, when there were no set guidelines. Khalili did a revision for Maugh’s husband, Thomas.

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But Maugh, a scientist by training, backed out of the surgery three times before finally deciding to do it. The intensive pre- and post-operative commitments seemed to be too much.

“I definitely regret not having the surgery sooner,” she told Healthline. “The surgery gave me back my life and then some and I wasted all those years. I backed out because I was afraid of anything that radical, but it was an unfounded fear.”

Some opponents of bariatric surgery have said it should only be used as a last resort. In fact, that’s the opposite of what we should be doing to realize optimal savings to the healthcare system, Morton said.

Maugh agrees. “I have definitely saved money and the ‘system’ has benefited as well. Medicare and my supplemental insurance pays most of my medical and handles the deductible and the co-pays on the prescriptions,” she said. “Since the surgery, I am on no medications and therefore no co-pays. I recently began a prescription medication for neuropathy but that has nothing to do with the surgery with the exception if I had controlled my diabetes earlier in the progression of the disease I might not have neuropathy now.”

Morton said about 80 percent of bariatric surgery providers are accredited by ASMBS. ASMBS-accredited surgeons commit to at least five years of follow up with a patient after surgery. 

Basseri said obesity has put a strain on the healthcare system that bariatric surgery is attempting to ease. “We’re too sick as a country," he said. "Individuals in this country need too much treatment.”