Bruce M. Wolfe, M.D., adjunct professor of surgery (bariatrics) at Oregon Health & Science University School of Medicine, OHSU Digestive Health Center, and John M. Morton, M.D., M.P.H., of Stanford University, Stanford, Calif., have written an editorial in response to three studies on bariatric surgery published in the Wednesday, Oct. 19, issue of the Journal of the American Medical Association.
One of the studies to be published this week, "Early Mortality Among Medicare Beneficiaries Undergoing Bariatric Surgical Procedures," was conducted by David R. Flum, M.D., M.P.H., of the University of Washington, Seattle. Flum and colleagues studied the risk of all-cause early postsurgical death among Medicare beneficiaries undergoing open bariatric surgery -- surgery on the stomach and/or intestines designed to promote weight loss. The study examined early (30-day, 90-day and 1-year) death figures for all U.S. fee-for-service Medicare beneficiaries who underwent bariatric procedures from 1997 to 2002. Flum and colleagues concluded the risk of early death following surgery among Medicare beneficiaries undergoing bariatric surgery was considerably higher than prior case series have suggested and was strongly associated with advancing age, male sex and lower surgeon volume of bariatric procdures.
In an accompanying editorial, Wolfe and Morton write:
"These studies contribute important information regarding morbid obesity and its treatment. Morbid obesity is a significant health concern and bariatric surgery offers a potentially effective and enduring treatment for weight reduction. Bariatric surgery results in long-term weight loss, helps resolve comorbidities, provides a survival benefit, and has increased substantially as a direct consequence of its success in treating morbid obesity.
"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. Bariatric surgery may be a potentially life-saving intervention in the right patients and in the right surgeons' hands. The studies presented in this issue indicate that experience and technique count
"Given that obesity is a societal concern, there must be societal solutions and perspective. Prevention initiatives, medical alternatives, and new technologies may emerge in the future to help combat obesity. However, bariatric surgery today remains a fundamental therapy for morbidly obese patients. The studies by Santry et al, Zingmond et al, and Flum et al must be seen as opportunities for improvement in bariatric surgery, not as support for exclusionary practices by payors for patients in dire need. Instead, bariatric surgeons must meet the challenge of safely and efficiently providing this essential therapy for the most imperiled patients."
In the United States, most adults are overweight or obese, and obesity is soon to become the leading cause of death, according to background information in Flum's article. Bariatric surgical procedures are the only interventions that consistently help patients achieve significant and sustained weight loss and improvements with co-existing medical conditions. As a result, there has been dramatic growth in bariatric surgery over the last decade. Balanced against these beneficial effects, however, are the risks of perioperative death and short-term adverse outcomes, which have been poorly defined in the community at large.
"There may be several reasons for these findings," Flum and colleagues write. "Older patients do not tolerate surgical stress as well as younger patients and may also have less benefit after surgery than younger patients because much of the impact of obesity on organ systems, such as the heart, may have occurred by the time of the operation. It also remains to be seen if surgical weight loss in older patients decreases utilization of health care resources, improves functional status and quality of life, or extends survival as has been suggested in studies of younger patients."