Tuesday, April 19, 2005

Gastric Bypass in the News

Since I perform these operations (my group has had a program for 25 years), I have been reluctant to say much about gastric bypass surgery. But, you just can't get on the internet, look at a magazine, watch TV or read the newspaper without running across morbid obesity and gastric bypass stories on a daily basis. This USNews.com article and this WashingtonPost.com article basically are saying the same thing: patients tend to do better at centers where a high volume of gastric bypasses are performed. When the article (here's the abstract) is actually read, however, it is really a documentation of their own learning curve --- patients do better with laparoscopic RYGB now than earlier in their experience. There are a large number of procedures for which a "learning curve" is reasonably well-documented, and this is certainly no different. Somehow, this learning curve process is being construed as "don't go where the surgeons haven't done X number of these operations."

In some respects, this benefits me. I work at a tertiary care facility, and we have a high-volume program with a very good (0% 30 day mortality) track record. What is troubling to me, however, is the way that major university programs and the American College of Surgeons may use this as a means to eliminate some of their competition. If a low volume program has the same complication and mortality rate as the big university, should it be shut down because of potential problems based on statistical predictions? Should there be a moratorium on new programs based upon these statistical predictions? We can also turn it around --- why should Tufts have gone through this learning curve process, when there were other, older programs in existence who had better records?

Beyond the surgical politics, there is something more important that needs to be driven home, and the news media does not seem to "get it." These patients are not healthy! To expect superb outcomes and a zero M&M rate with gastric bypass procedures is to ignore reality --- these patients come to the OR with sleep apnea, diabetes, cardiac disease, restrictive lung disease, hypertension, ..... etc. Some are clearly better candidates than others, but many would not be a good candidate for any other operation. It is therefore unreasonable to "shut down" programs based upon postoperative mortality unless it can be demonstrated that proper care was not administered.

Patients should be encouraged to investigate the physicians and facilities at which they will receive their elective surgical care. The facts, however, are often much more complicated than sheer volume of procedures.