Sunday, September 5, 2010

Gastric Bypass Surgery: Cure or Disease?

Last week, a female patient saw me in the office for the first time to discuss her chronic digestive issues. Luckily for her, my recommendations did not include probing into her alimentary canal with the endoscopic serpents that we gastroenterologists rely upon.

As the visit concluded, she advised me that she intended to have a gastric bypass (GIB) procedure performed, and even used the medical term of bariatric surgery. I suppose that she mentioned it because the issue falls within my specialty, and she wanted my reaction to her plan, although she didn’t directly solicit my opinion. Nevertheless, she received it.

I am not surprised anymore when the critical medical issue emerges at the end of the office visit. Every physician has this experience regularly.

“So, Mrs. Fleets, I think that this new medicine will really help your constipation. My nurse will be happy to arrange your next appointment. Do you have any questions?”

“How come I now have trouble breathing when I walk up stairs?”

What struck me about my bypass seeker was that she didn’t appear to have the bulk that would justify weight loss surgery. Sure, she was overweight, but she was thinner than many patients are after undergoing a gastric bypass operation. She was in her thirties and was not suffering from any pulmonary, cardiac, endocrine or rheumatologic consequences of obesity. She simply wanted to be thinner.

I asked her what other treatments she had pursued, since clearly surgical treatment of obesity should be the last option. A patient’s typical response to this inquiry is a narrative describing a series of diets and medications that produced only modest and transient benefit. When no other means can peel the pounds off, and the health consequences of the heft are significant, then surgery is worthy of consideration. But, this is a very weighty decision and the scales should not be tipped too easily in favor of surgery.

This patient had never been on a serious diet or enrolled in a weight loss program. I suggested Weight Watchers, a legitimate, effective and affordable program that encourages the client to make lifestyle changes that are sustainable. Of course, we live in an era of short cuts and gimmicks where infomercials promise us potions that will transform us from Michelin Men into taut lifeguards in a matter of weeks. She responded that she doesn't have the time for the meetings.

Doesn't have the time? My patient had no clue how much commitment and discipline gastric bypass surgery demands. If she couldn’t accommodate a weekly meeting, then how would she ever accommodate to her new intestinal anatomy? She was exactly the wrong candidate for the operation.

I explained to her that gastric bypass is major surgery with all of the risks of any abdominal surgery. More importantly, I emphasized to her that even when the operation is successful, it changes your life every single day forever. The dining experience, one of society’s most important social and familial forums, would be irrevocably altered. Bypassed patients knowingly forego gastronomical pleasure to serve a greater good.

Moreover, a gastric bypass procedure can redirect the internal plumbing, but it cannot unravel the psychological aspects of the disease. If the latter is not properly treated or screened for, then patients can undergo a bypass and actually gain weight. There is no bypass that can restrain a patient from ingesting several milkshakes a day.

Removing an appendix or a gallbladder won’t change your life. GIB profoundly disrupts nature’s digestive system. Only very small meals can be ingested. There are a host of nutritional deficiencies that can arise, because there may not be sufficient intestine available to absorb necessary nutrients.

Do I favor the operation? Yes, but only for a proper candidate who has been carefully vetted by medical and psychiatric professionals. Hundreds of thousands of Americans will have the surgery this year. The medical threshold for determining eligibility for bariatric surgery is becoming steadily lower. I wonder if the acceptance criteria have become too lenient. Of course, the operation is being marketed hard across the country to keep operating rooms humming. Bariatric surgery is big business.

Will this patient get the operation? I hope not, because I don’t think she has the mettle for her post-operative life. If I were the consulting surgeon, I would certainly ‘bypass’ her and direct her back to some treatment options that really work and have no risk.

Once again, I know that GIB is the right choice for many patients who are suffering and have no other remedy available. But, we live in a ‘cut & paste’ society where we often opt for short cuts and secret passageways to success. GIB is no short cut; it’s a surgical incision that may create a deep wound that will not heal.

7 comments:

LeisureGuy said...

People love "quick" and "easy" and that love is continually stoked by businesses trying to sell their wares. The voice of business is quite loud and tends to drown out other voices.

Anonymous said...

Great post. In Los Angeles every other billboard is for lap band surgery and
there seems to be a clinic on every corner. It makes it seem like a
manicure. You are correct that there can be physical repercussions to
bariatric surgery and it is not something to be undertaken lightly.

You ask; "I wonder if the acceptance criteria have become too lenient?" I
think the acceptance criteria is an active credit card!

Toni Brayer, MD

Anonymous said...

As a patient who lost the ability to eat food from gastroparesis, this is just distressing to me. People do not understand how important eating is to us - socially as well as for nutrition.

If this person decides to go forward her life will be forever changed and not necessarily for the better. nerves can be severed and emptying can stop altogether. This is both unhealthy, painful and downright dangerous for some. There is no reversing the decision! Even a tattoo can be removed, but this is permanent. just imagine never being able to "enjoy" a meal again. I can still go to a restaurant, can enjoy the social aspect and the smell of the amazing food, but cannot put it in my mouth. There is no "cheating" with this condition unless a trip to the ER is wanted. (?) It just is awful. I rely on a feeding tube permanently inserted into my intestines for nutrition.

It saddens me so much to see the quick fix option even considered for someone who doesn't have a serious problem. I also believe this surgery is sometimes necessary, but I would hope that those who seek it also seek mental help because believe me, they will need it.

L

GlassHospital said...

I like the topic of this post--and I think you're absolutely right in your opinion.

So much in medicine has moved from the extraordinary to the mundane that we've become cavalier.

Look no further than the NY Times investigative series on over-exposure to radiation. Is it any wonder we hurt people when we get CT scans for just about everything now?

I wonder if your patient will go forward with her plans. No doubt, given her determination, she will. The fact that she only brought it up at the end of the visit meant she was looking for your blessing. Your attempt at dissuading her, while right, will likely only serve as a haunting "I told you so" down the road if her psyche allows her to remember it.

Important post!

Anonymous said...

Kirsch.. I'm shocked you didn't post a topic downplaying that study regarding med mal and ~2.4%. I'll let you google it and not post anything more about it.

Michael Kirsch, M.D. said...

Yes, I am well aware of the Health Affairs report from this week. However, this is a medical quality blog, not an exclusively medical malpractice blog. I'm sure you have views also that extend beyond the medical malpractice arena. Feel free to comment on this week's (non-legal) post.

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