Bariatric Surgery: Reoperations Are Common

Finally some truth about bariatric surgery! Many bloggers have been critical of bariatric surgery since the beginning and declared that it was the surgeons lining the pockets with the money. I still think much of this is correct, but for some time, the remission – not a cure – for type 2 diabetes was the only headlines.

Nearly 1 in 5 patients with a lap-band undergo multiple device-related reoperations, and complication rates vary widely between hospitals. Bariatric surgery is increasingly common in America, but care and outcomes vary greatly between centers, research finds.

Every year, nearly 200,000 Americans turn to surgeons for help with their obesity, seeking bariatric surgery to lose weight and prevent life-threatening health problems. But after more than two decades of steadily increasing numbers of operations, American bariatric surgery centers still vary greatly in the quality of care they provide.

That’s the finding of a team of researchers at the University of Michigan who used data from insurers that pay for bariatric operations, and from a statewide partnership of bariatric surgery teams, to study the issue of bariatric surgery outcomes.

Just in the past few months, the U-M team has published several papers that shed new light on the high level of variability and incidence of complications that patients still face.

“As Americans turn to bariatric and metabolic operations in higher and higher numbers, and as our county grapples with the ongoing obesity epidemic, it’s more important than ever to take a clear-eyed look at how well our surgical centers are doing, and to try to improve the care patients receive,” says Andrew M. Ibrahim, M.D., M.Sc., the Robert Wood Johnson Clinical Scholar and U-M surgical resident who led many of the new studies as part of his work at the U-M Center for Healthcare Outcomes and Policy.

Their most recent findings:

• Nearly 1 in 5 patients with Medicare who have laparoscopic adjustable gastric band surgery will end up needing at least one more device-related operation, either to remove or replace the band around the upper portion of their stomach, or to switch to a different stomach-remodeling approach. The results were published in JAMA Surgery.

• Additional device-related procedures for the operation were so common, in fact, that nearly half (47%) of the $470 million paid by Medicare for such procedures was for reoperations to revise or remove it. “If half the money we’re spending on a device is to revise or remove it, we ought to ask ourselves if we should still be using it,” says Ibrahim.

• Though this form of bariatric surgery has declined sharply in popularity in recent years, and now makes up only about five percent of all operations, there are still hundreds of thousands of people who have the devices from past operations. So failure of the devices to result in weight loss, or complications from their placement, pose a potential major issue. The study finds tremendous variation between surgical centers in the rate of reoperation that their patients faced.

• The new study looks at data from 25,042 people who had operations between 2006 and 2013, and who were covered by Medicare, which pays for about 15 percent of all bariatric operations.

Reference: JAMA Surgery, doi: 10.1001/jamasurg.2017.1093

• Another recent paper from the U-M team finds that even accredited bariatric “centers of excellence” can vary greatly in the rate of complications their patients suffer after their operations.

• Published in JAMA Surgery, the study looked at data from more than 145,500 patients and found a 17-fold difference between the centers with the highest and lowest rates of serious complications. It found that even within a single state, one bariatric surgery center can have nine times the complication rate of another center.

• “While we have made significant progress improving the safety of bariatric surgery over the last two decades, the presence of 17-fold variation in complications rates across accredited centers underscores that we need to improve further,” Ibrahim notes.

Adverse Topics in Bariatric Surgery

On Saturday, Max called and asked if I could come to his place. I agreed and when I arrived, Tim, and two other members of our support group were present. Max said that the three of them had been approached by the hospital and doctors to have bariatric surgery. Max said he had turned them down, but the other two had agreed to an appointment which would be the following Wednesday to see if they qualified for the surgery.

Max asked me if I had been approached and I said not this time. Max said he would not consider bariatric because of all he had read and that I had blogged about recently. I said there is a lot more that needs to be blogged about and I have five or more topics to work on writing. One of the two spoke up then and asked why we would not consider bariatric surgery.

Max and I started listing the reasons:

• You would not be told everything you will need to know
• You will only be able to eat a spoonful of food at any one time.
• You will need to wait once you swallow before you can have a swallow of water
• You cannot drink or should not drink any alcohol
• You may have diarrhea or vomiting
• You will have many vitamin and mineral deficiencies and may require shots for the vitamin and minerals to be of any value
• Most oral medications may no longer work
• Insulin may be required to manage your diabetes
• You will need mental health counseling
• You will possibly lose the ability to detect hypoglycemia
• About three to five plus years later, your risk of suicide increases

I said these are the ones we can think of immediately, but there are more. Yes, your diabetes may be put in remission about 12 to 18 months after the surgery, which is a good thing.

The next thing you need to be aware of is the small amount of food you will be able to consume without stretching you stomach. This is a big problem for most people and when they do this, they will regain much of the weight and diabetes will return. Several of the people we know have needed a second surgery to repair the stomach and the cycle can repeat itself.

Several things you need to be aware of before consenting to the surgery. Always make sure that you have a meeting about the side effects several days before the surgery is scheduled. Many surgeons rush you into surgery and never cover the side effects. Others present you with a consent form just before surgery and expect you to sign it without reading it. Whenever any of these happen, you would be wise to walk away and never look back.

Many of these surgeons are only interested in the money and not your health. They will not do anything for you after your surgery and seldom cover the things that you need to do following surgery.

A minority of bariatric surgeons will do things correctly and do tests before and after surgery to make sure that your primary care doctor follows through with the care and tests necessary.

Bariatric Surgery Now Recommended For Many Type 2's

Do we need these guidelines giving surgeons the right to do surgery when the patients don't want it?  You will have to think fast to avoid this surgery.  These surgeons must be so desperate for money they are trying anything to bring in the dollars.

The new clinical guidelines were published May 24, 2016. The sad part is that they are endorsed by leading international diabetes organizations, including the International Diabetes Federation (IDF). The guidelines call for bariatric surgery, involving the manipulation of the stomach or intestine and this is to be considered a standard treatment for type 2 diabetes.

The guidelines, published in Diabetes Care, recommend surgery to induce weight-loss for certain categories of people living with type 2 diabetes, which accounts for the majority of the estimated 415 million cases of diabetes worldwide. The recommendation is based on evidence from multiple clinical trials that bariatric surgery can improve blood glucose levels more effectively than lifestyle or pharmaceutical interventions in obese people with type 2 diabetes.

What few of the studies addressed are the nutritional problems caused by bariatric surgery. Another missed topic is the percent of bariatric surgeries that are undone by patients overeating and stretching the stomach. These are two of the serious problems created by bariatric surgery, which are seldom addressed until too late. This often causes serious health problems for the surgery patient as I talked about in this blog on vitamin D deficiency.

While being overweight and obesity are major risk factors for type 2 diabetes, many of these people don't develop type 2 diabetes and I fear that many will be bullied into surgery with the nutritional problems becoming worse for people under going bariatric surgery.

At least the authors admit there are risks of complications and long-term nutritional deficiencies that require rigorous long-term follow-up by expert teams. The IDF estimated that in 2015 over $670 billion was spent globally to treat diabetes and prevent complications. Despite this, less than 50% of people with type 2 diabetes currently achieve the appropriate blood glucose levels to avoid or reduce the risk of long-term complications.

The new guidelines, which emerged from the Second Diabetes Surgery Summit (DSS-II) held in London in September 2015 as a collaboration between IDF, Diabetes UK, American Diabetes Association, Chinese Diabetes Society and Diabetes India, recommend bariatric surgery for people with type 2 diabetes who have a BMI of 40 and those with a BMI of 30 who are not able to adequately control their blood glucose levels through other means. This threshold is lower for people of Asian descent.

This is the first time that guidelines recommend surgery as a specific treatment option for type 2 diabetes.  Also read this article which they label as metabolic surgery.  This is becoming the hot topic in most medical sources and WebMD has an article about weight loss surgery for people with type 2 diabetes.

Bariatric Surgeons Don't Do Nutrition

Bariatric surgeons are finding out that they have problems in many patients that they have operated on and this is the high risk of vitamin D deficiency and insufficiency among bariatric surgery patients. Both referring physicians and bariatric specialists need to take a greater role in personalizing vitamin D supplementation regimens in these patients.

Even most referring physicians aren't aware of the importance of early vitamin D intervention or may not be addressing the issue in the most effective manner. Even with the latest medical research, doctors specializing in bariatric surgery do not yet know the best vitamin D supplementation regimen for these patients. As a result, the referring physicians and bariatric specialists should be working together to closely monitor and tailor an individualized supplement regimen for each patient.

The best method of treating vitamin D malnutrition pre- and post-bariatric surgery is to deliver a higher daily dose of vitamin D and then adjust to the appropriate blood 25(OH)D readings, which will require personalized medicine and treatment from both referring physicians and bariatric specialists. Personalized vitamin D supplementation will prevent both under- and overtreatment in bariatric surgery patients and is likely also important for many other patient populations who are at risk for vitamin D deficiency, including people who have obesity or in those who are overweight.

Until recently, vitamin D deficiency after bariatric surgery was thought to be due to side effects of the procedure, i.e., poor absorption of fat-soluble nutrients. It has been determined now that vitamin D deficiency stems of pre-surgery malnutrition with up to 98 percent of bariatric surgery candidates having vitamin D deficiency. This malnutrition persists after surgery despite supplementation and weight loss, which theoretically releases vitamin D stored in the fat.

The primary concern over vitamin D deficiency is that the risk of deficiency is even greater after bariatric surgery when these patients may be less able to absorb vitamin D, and, thus, treatment before surgery may be more effective. Improving vitamin D status before surgery may also improve healing and shorten the length of stay in the hospital following bariatric surgery.

What is an optimized vitamin D level in a patient before or following bariatric surgery? According to the 2013 American Society for Metabolic and Bariatric Surgery guidelines, physicians should bring blood concentrations to greater than 30 ng/mL of 25-hydroxyvitamin D, the circulating form of vitamin D. The society recommends achieving these readings by delivering the standard daily dose of at least 3,000 IU, test the patient's blood, adjust the dose, test again and repeat until the patient's vitamin D readings are optimized. A physician may consider giving high doses of vitamin D -- 50,000 IU one to three times weekly or even daily -- if necessary for patients following surgery. The recommendations from the society sound like a ringing endorsement for personalized medicine.

A key consideration in vitamin D supplementation that physicians need to be aware of is the form of vitamin D given. Vitamin D3 is made in the skin during sun exposure and is found in over-the-counter supplements, whereas vitamin D2 is uncommon in the diet and found in high-dose prescription vitamin D supplements. In a meta-analysis of 57 studies, patients given vitamin D3 had an 8.08-ng/mL larger improvement in 25(OH)D readings over the same dose of vitamin D2 -- meaning vitamin D3 proved more effective. Despite this, many doctors inadvertently prescribe vitamin D2 to their bariatric surgery patients. Many doctors do not realize that writing a prescription for vitamin D will likely yield vitamin D2, and many also do not know the difference in effectiveness between these two forms. I recently showed that 87% of our bariatric surgery candidates prescribed high-dose vitamin D were given vitamin D2, despite that many patients only get a short window for preoperative treatment.

As for the appropriate dosing regimen, of 25 separate studies testing different regimens, none of these studies reported consistently optimized vitamin D readings in patients. These studies ranged from a daily multivitamin to high doses of vitamin D (50,000 IU monthly or weekly) and various combinations of daily and high doses. These findings from my recent review echo the society's recommendations, yet no studies giving dosages up to 5,000 IU daily reached optimized vitamin D readings universally. However, some patients did reach blood concentrations over the recommended 30 ng/mL. Would the best course of treatment really be to increase the standard dose for all, or should we only increase the dosage for those patients who are still below the recommended concentration?

With this discussion, I also have to wonder if the other vitamins and minerals are monitored and kept at the correct levels as I have seen other studies reporting deficiencies in other vitamins as well.

Bariatric Surgery Often Leads to Suicide

Surprise, this information has made many medical papers and they all refer to this Los Angeles Times article. This is another case of bariatric surgeons not giving their patients all the information they need to make informed decisions. They are so interested in the money they make that many push patients to make bad decisions. Vital information is not given to the patient and good questions patients do ask are often brushed aside.

Now I can't put all the blame on the surgeons although they shoulder most of it for not recognizing this group. I am referring to those that are so determined to lose weight that even good sense goes out the window and they often lie to the surgeons to make sure they get the surgery. They are often so vain that they will do anything to rid themselves of a few pounds. Most may have type 2 diabetes, but a few do not.

According to the study, in the three years after they go under the knife, patients who have bariatric surgery to aid in weight loss are more likely than they were before the operation to attempt suicide or end up in the hospital after doing harm to themselves.

A Canadian study that tracked 8,815 bariatric surgery patients found that in their three post-surgical years, 1.3% of those patients landed in the hospital following a self-harm emergency, which included intentional drug overdoses or suicide attempts by other means. However, that rate of self-injurious behavior represented a 54% increase over that seen in the same patient population during the three years before these patients had surgery.

Among those most likely to experience self-harm events following surgery were low-income patients and those living in rural areas. The research highlights a little-recognized challenge patients face in the wake of surgery that replumbs the stomach but also drives far-reaching changes beyond the digestive system.

The authors of the current study suggest that changes in patients' ability to metabolize alcohol in the wake of bariatric surgery might be implicated in some patients' worsening mental health. Certain bariatric surgery procedures that bypass parts of the stomach, patients who drink alcohol often find their tolerance low and become inebriated quickly. Such changes, wrote the study's authors, may affect some patients' risk-taking behavior and ability to suppress self-destructive impulses while under the influence.

Following surgery that limits stomach capacity, in the current study, 68% of the 168 self-harm emergencies noted were attributed primarily to medication overdoses. The study's authors also urged further research into the possibility that altered brain chemistry wrought by the surgical replumbing of the digestive tract might contribute to depression or suicidal behavior.

Most surgeons don't think of this and most ignore questions about this. The research also underscores the need for bariatric surgery practices, a specialty seeing rapid growth, to tend to the mental health of their obese patients not just before surgery, but for several years beyond. Most of the bariatric patients' psychological crises occurred in the second and third years after surgery, a period when there's little interaction between patients and the practices that provided their bariatric services.

The surgeons in the United States were of the opinion that they screened their patients more carefully and had contact with their surgery patients longer than the study indicated. It could be interesting to have a study done on patients in the United States to see if the surgeons really know what they are talking about and actually do what they say.

Bariatric Surgery Not a Saving In Long-Term Costs

A study finally tells the truth about bariatric surgery. Even though it is not said, the only ones benefiting are the surgeons. Long-term cost savings do not happen and no evidence was found that one type of bariatric surgery produces more savings than another. This is what a 6-year analysis of private health insurance data has found.

Of course, they don't want to offend the surgeons, so Jonathan P. Weiner, DrPH, professor of health policy and management from Johns Hopkins University, Baltimore, Maryland says to assess the value of bariatric surgery, future studies need to concentrate on the benefit of improved health and well-being of patients undergoing bariatric surgery, rather than on cost savings.

JAMA deputy editor, Edward H. Livingston, MD, says that the findings call into question whether bariatric surgery is worth the cost. Then he says bariatric surgery has great short-term results, but over the population, its outcomes are less impressive.

Robin Blackstone, MD, medical director of the Scottsdale Healthcare Bariatric Center, Arizona, and immediate past president of the American Society for Metabolic and Bariatric Surgery disagrees and states the value of the life after bariatric surgery should not be measured by claims data. She claims that patients often have remission of their major medical problems, get off medications, and increase their work productivity.

It seems everyone wants a say in this article. The study, published online February 20 in JAMA Surgery, was comprised of 29,820 adult members of 7 Blue Cross/Blue Shield plans who underwent bariatric surgery during 2002 – 2008. Each patient was paired with one control patient who was obese patient. The paired patients did not undergo bariatric surgery, but did have related conditions of hypertension, type 2 diabetes, sleep apnea, metabolic syndrome, and other health conditions.

The controlled pairs were also matched to the surgery patients for age, sex, and other factors, including obesity propensity score, a measure developed by the authors for identifying obese patients from claims data. This study is interesting because the long-term costs were very close and that is the reason no one class of obese patients that underwent surgery can be said to be more cost effective than another when compared to obese patients that did not undergo surgery.

A fault of the study is the fact that no quality of life data were included and that is the reason the bariatric surgeons are calling for more studies. It can be seen that bariatric surgeons are downplaying this study to prevent it from cutting into their revenue stream. Yet they do not educate the patients about the problems or side effects of the surgery. All they do is hype to the benefits.

Diabetes Bariatric Surgery – Is It Effective?

Why are bariatric surgeons becoming so active in the diabetes field? Quite simply, primary care physicians and endocrinologists have abdicated their position. Sound a little dire? It might, but considering that these doctors are not rising to the challenge of taking care of and getting people out of the moderate to mildly obese categories. The bariatric surgeons are stepping in to the void to increase the thickness of their wallets and retirement plans.

As long as no one is explaining the side-effects and hyping the benefits, these surgeons will be happy to fatten their wallets and retirement accounts at the expense of other doctors, patients, and medical insurance companies. Is there a need for this surgery? While I don't like to say so, yes, there is a need. For those individuals that have tried and failed, e.g., exhausted with honest efforts other ways to reduce weight, and are among the morbidly obese, then the surgery is probably the only route available to them for weight reduction and possible management of diabetes.

Am I opposed to bariatric surgery. YES, except for the case above, I think the bariatric surgeons are into the vanity game for many people. I am thankful that the American Heart Association has taken a position in this and I can agree with their position. Read the article about this here.

The fees for bariatric surgery are steep and unless you have exceptional medical insurance, you may need to pay a healthy part of the bill. A discussion of medical insurance, Medicare, and Medicaid can be found here. Be sure to study this carefully.

An article by the Mayo Clinic is here. This is one of the better discussions about the different types of bariatric surgery and does list most of the risks involved with the surgery and even some risks by type of surgery. If you are seriously considering bariatric surgery, please read this article in its entirety. The consequences of not following exactly the plan and lifestyle changes can be very costly and even deadly. Most medical insurance companies require that you complete a training period and know each and every risk in detail. Some vary in length, but six weeks seems to be a minimum.

Some surgeons may try to get you past the insurance requirements fearing that you will want to back out of the surgery. So even with this, I strongly urge you to do your homework and know what you will be facing beforehand. Bariatric surgery is not for everyone so don't feel that you can slide past the requirements for lifestyle changes as they are mandatory and you will have problems if you ignore them. These lifestyle changes are permanent for the rest of your life which many people cannot accept and this gets them into serious problems.

If you think I am being overly dramatic, use your search engine and do some checking on your own. Also read my blog here about bariatric surgery possibly masking diabetes. Do not think it is the absolute cure the bariatric surgeons want you to believe. There are news articles almost weekly now hyping bariatric surgery and all refuse to discuss the serious risks. Even though I have an agenda against this surgery, I hope that I have pointed you in the right direction to arrive at an informed decision.