Bariatric surgery – Let’s make the world thin-k again!
|Article by – Moshe Schein|
If you are a dedicated bariatric surgeon or inflicted with a strict, politically correct personality then this piece is not for you—continue reading, instead, the latest issue of Obesity Surgery (impact factor-3.6!) where you will find highly scientific and clinically relevant articles such as “Percutaneous Electrical Neurostimulation (PENS) of Dermatome T6 with an Ambulatory Self-applied Patch vs PENS of Dermatome T6 with Conventional Procedure: Effect on Appetite and Weight Loss in Moderately Obese Patients”.
A few disclosures, before the rant begins:
Some of my good old friends are great bariatric surgeons. Two or three of my best past residents have become leaders in this lucrative field. For the sake of friendship, when we meet we talk mainly about wine and cigars.
I do refer patients for bariatric surgery. When I come across patients who eat themselves to death I send them to trusted local bariatric surgeons—I know that this is their last chance.
I confess that in the remote past—when I was young and immature– I had “experimented” with surgery on the fatties. So in South Africa I embarked on vertical banded gastroplasties –I remember having to fish out, later, pieces of the eroding mesh through the gastroscope. Even later, in Israel, I experimented with a “new” procedure I’d read about –a modified jejuno-ileal bypass. The “modification” included the creation of an anti-reflux intussusception valve in the distal ileum, allegedly to prevent reflux of bacteria into the bypassed, now blind, loops of bowel. The patients lost weight rapidly—within a few months they begged me to reverse them because of the intolerable diarrhea. One developed hepatic dysfunction despite the gimmicky anti-reflux valve.
Fortunately, I gained my senses and I perceived that operating for obesity is not something that I enjoy and decided to stay away from this glorious enterprise. By that time the laparoscopic revolution began to gain momentum. I moved to New York and started working under a Boss who continued doing open gastric bypass operations while people rushed to do it laparoscopically. Gradually I was introduced to the medico-obesity industrial complex that was blossoming in the USA and around the world—to which I developed distaste for the reasons mentioned below, in random order.
Let’s starts with this: the notion that surgery can solve the problem of obesity is ridiculous. It has been estimated (in 2010) that 15.5 million adult Americans or 6.6 percent of the population had an actual BMI over 40. Compare this figure with the 196,000 Americans who underwent bariatric procedures in 2015. Like a drop in the ocean. Clearly bariatric surgery cannot be portrayed as a solution to the fat population—not in the USA and surely not around the plumping world.
Undoubtedly, bariatric surgery has evolved into a huge global industry. When weight reduction procedures became laparoscopic, and thus perceived “easy” on the patients, the numbers skyrocketed. And very soon surgeons and departments understood how financially lucrative it was and jumped on the bandwagon. The so-called bariatric centers mushroomed all around–some nominating themselves centers of excellence — and bariatric procedures have become one of the most common general surgical procedures performed these days.
The emerging leaders in the field –gathering huge personal series in one of the procedures perceived by them as the ”best” (before they change their mind and switch over to a “better“ procedure) established “fellowships” to train generations of followers. Such fellowships– heavily sponsored by the laparoscopic device industry–while portraying themselves “advanced laparoscopy fellowships” essentially focus on bariatrics and eject into the surgical world a constant stream of surgeons who can create a gastric sleeve in 30 minutes but tend to graduate with hazy notions of “real” general surgery. For example—he or she can go through three lap gastric bypasses in one morning but never heard about the option of lap subtotal cholecystectomy for the “difficult” gallbladder.
Like each great industry, this field needs to appear academically respectable as well: hence we have bariatrics clubs, societies, courses and a spectrum of journals dedicated to his field—all overtly (now more covertly) supported by the industry—like Wall Street supporting USA politicians. Open a “throwaway”, industry supported, journal like General Surgical News, and see how disproportional large is the space dedicated to articles glorifying weight reduction procedures—portrayed as a solution to everything including depression and impotence.
As with plastic-cosmetic surgery the access to bariatric procedures is limited—even in countries like the USA where most insurers claim to cover the procedures. But in my experience it is usually those who need the procedure most who are rejected. I see the very poor, mega-obese with BMIs of 58 who are not insured; I see those who are not educated or motivated enough to follow the strict requirements mandated by the so-called bariatric centers of excellence before being accepted “into our program”. At the same time the well-insured lady with borderline obesity has no problems. And the wealthy—they can pay for anything they wish. I see desperate uninsured fatties traveling to Mexico where they can have it done “cheaply”. You go to Tijuana –a gastric band for 1999 bucks, a sleeve for $3999. Chop, chop, click, click and you fly back. And a few days later you present in our ER with pus pouring from the band port site or (oi vei) bile from the port site after sleeve gastrectomy. What then? Back to Mexico or to the local ivory tower for a hospital stay which costs a few hundred thousand dollars and ruins your uninsured life.
Let’s talk about complications. Typically in published series of say “1000 sleeve gastrectomies without a single mortality” the picture looks rosy—they want us to believe that those operations are safe—only if performed in great hands as theirs’. But in the real world—outside the publication bias– the situation is much less perfect. Not a few months pass without somebody telling us about so-and-so who died after a gastric bypass. Often we come across patients who describe their own nightmarish string of post bariatric complications. Even those whom one can consider “success stories” tend to experience some permanent morbidity—the bleeding gastric ulcer after gastric bypass, the intestinal obstruction, the hernias—not to speak about life long dietary restrictions and deficiencies. Hurray — we mutilated your stomach in order to improve your diabetes because you were not disciplined enough to stop gorging yourself with pizzas. You are a story of success!
In parallel, complications of bariatric surgery have become a common cause for malpractice litigations. Having reviewed a significant number of such cases (they continue gathering) I am familiar with a pattern: a serious complication develops after a “bypass” or a “sleeve” performed in some private center. What follows is a cascade of delays and therapeutic chaos involving a mishmash of re-scopes, re-laps, percutaneous drains, stents, endoclips, glues—each surgeon cooking his soup d’jour. I even reviewed a case against a leading professor of surgery who treated an early leak from the gastric pouch after gastric bypass with total gastrectomy and intrathoracic esophagojejunostomy. All hell broke loose! Sadly, my observations suggest that some bariatric surgeons forgot the basics of general surgery and thus do not adequately treat their complications. Some do not seem to have time for the complications—the waiting list is waiting!
Another problem is that general surgeons who do not engage in bariatrics are reluctant to treat post bariatric surgery complications—not even the late ones. For example: a patient presenting with small bowel obstruction years after a gastric bypass. The original bariatric surgeon is out of town but none of his colleagues would accept a patient now labeled as bariatric — “transfer him!”
The situation in the developing world is even more depressing: for isn’t it upsetting to see chubby (not morbidly obese) ladies undergoing fancy bariatric procedures in a country where hundreds of millions are walking hungry or defecate in the street outside the laparoscopic clinics? In countries lacking basic medical infra structures entire surgical conferences are dedicated to the newest bariatric procedures. International surgical charlatans are flown in by the industry to promote yet another “improved” procedure which superficially appears “easier”—you can do a few of those each morning. So let us do an omega loop—a single anastomosis. Bile reflux? Forget about it—just add a few anti-reflux sutures. So the new “mini” operation is becoming the new standard—until another genius comes with another idea. All lessons of the past—remember the long term problems in patients after partial gastrectomy for peptic ulcer?—are ignored. And who knows how many people are mutilated or killed around the world by misguided or botched bariatric procedures? No word about this in the dedicated obesity Journals.
In some 50 years from now, perhaps earlier but surely later, when historians will look at the surgical management of morbidly obese patients over the last 60 years (the first jejuno-ileal bypass was performed in the 1950s) – how we switched over from procedure to procedure (and are still doing so); how we accepted that it is standard of care and ethical to permanently mutilate the foregut of patients, only because they cannot control their appetite –they will be horrified. Bariatric surgeons’ defense of “it works” doesn’t give license to do as we please. Surgically distorting the one organ system of these folks that works very well seems perverse.
But meanwhile, my dear bariatric friends, as long as you can, enjoy and have fun. This would help you remain within the top 1% — while trying to help 1% of the morbid obese population.
Acknowledgement: I wish to thank Paul Rogers of Glasgow for his critique and input.