Monday, May 16, 2005

One Lap Band, and a Margarita to Go

Good, bad, or indifferent. That pretty much sums up the opinions about surgery for morbid obesity. I fall into the “good” category, but only for appropriately selected patients who fall into well-defined parameters. We could debate the pros and cons of bariatric surgery, and the different surgical options for hours, but I think most physicians agree that gastric bypass surgery is helpful to many patients. What is pretty well established, however, is that bariatric surgery is seen by many as a big, fat industry. There are online and print ads for bariatric surgeons, seminars, and a fair amount of press coverage, which makes the whole process seen as money driven. What gets lost is the reason to do this operation --- it is designed to eliminate the root cause of a hornet’s nest of medical problems. It seems that the Lap Band procedure, which is not covered by most insurance carriers, is associated with more of this type of advertising (I think that it may play only a limited role in bariatric surgery in this country in the long run; I’ll leave that for a future post).

Living in the intermountain west, and being a bit naïve, I was unaware that some patients are heading south of the border for weight loss surgery. Unable to get insurance approval for bariatric surgery or not interested in a more standard gastric bypass, they pay cash to have a Lap Band done in Cancun, Monterey, Mexicali, Tijuana, etc. This came to light when I received a page while on call from a patient who had just returned from Mexico after undergoing a Lap Band --- and she was having problems.

Now, it’s important to understand that weight loss surgery is a different animal in comparison to the remainder of GI tract procedures. Patients require extensive preoperative counseling and teaching, as their whole world is suddenly inverted --- they go from eating large meals to only ¼ of a Dixie cop of food at a time. They need ongoing teaching and support from their surgeon, dietician, psychologist, family, etc. It is hard to make this type of surgery into a “weekend getaway” and have success. The Lap Band, in particular, requires even more postoperative care --- patients need to see their surgeon about every two weeks, and the volume of saline in the band often needs adjustment.

The phenomenon of patients seeking “alternative” care (don’t get me started – just go to Quackwatch) in Mexico is nothing new. This situation is an extreme reach, however, and I think several factors are involved:

  1. The refusal of many insurers to cover an operation (Roux-enY gastric bypass) that has an excellent track record, good results, and the blessing of the NIH.
  2. Lap Band advertising promising that the procedure is “reversible and adjustable,” appealing to many patients.
  3. It is clearly cheaper for patients to go to Mexico to pay cash for this procedure than it would be for them to do the same here (many do pay out of pocket in the US for Lap Bands, and some for gastric bypass due to insurance exclusions).
  4. Most importantly, patients that have not been counseled about the indications for weight loss surgery, its risks, and its long term goals and outcomes can mistake this undertaking as “not that big of a deal.”
So, what to do? Besides the emergent issues involved for this patient --- potential for pulmonary embolus, a malpositioned Lap Band which may need further surgery or simply adjustment --- she needs instruction on how to eat, what to eat, what to watch for, etc. Who is to provide that for her? Who is to adjust her band if and when that needs to be done? I suspect her insurance company will not provide payment for any of this type of care here. Ultimately, she needs to decide where she wishes her medical care to be delivered.

At the risk of sounding too cheeky while talking about weight loss surgery, this is just a little “food for thought.”