WLS Article from my hometown paper

[Guest guest]

Note: This story is interesting in the sense that it stresses the

need, the ABSOLUTE NEED TO TAKE YOUR VITAMINS. There are 2 women in

the story who didn't. And how many people who have problems don't

talk to their surgeons. Why that is I have no freaking clue but there

it is.

Weighing the risks

In the world of before and after photos, Sandy Pierce is a size-4

celebrity.

She dropped from 302 pounds to 126 after her gastric bypass surgery in

2001.

Since then, she's become a strong advocate for other patients,

providing Encouragement and advice to hundreds who have had

weight-loss operations. She arranges visits to the hospital rooms of

people just undergoing the surgery. From her home in Cincinnati, she

runs a support group called " Midwest Losers. " Her work was honored

with an award last October at a national surgery trade show.

But she's paid a price to be thin: Five surgeries in four years for

related problems, including two hernias and three small bowel

obstructions. She was just diagnosed with a crippling vitamin deficiency.

She's 41 now. She wonders how much more her body can take.

" I'm second-guessing everything right now, " Pierce said recently. " Is

this what I have to look forward to the rest of my life? "

Questions like this have become increasingly urgent as weight-loss

operations surge in popularity, moving from the medical margins into

the mainstream.

The number of operations has skyrocketed 400 percent since 1999, to

140,640 last year. The procedure could soon surpass prostate removal

and hip replacement among top major surgeries.

The reason is simple. Obesity can cause debilitating medical problems.

And nothing else seems to work for drastic weight loss. Not diets. Not

drugs.

Surgery could solve a major public health problem in a country

obsessed with thinness yet facing an obesity crisis. Hyped by

celebrity testimonials and dramatic photos, surgery is now a favored

treatment in the battle against fat.

But behind the lofty claims, serious concerns about safety and

long-term effects are mounting, interviews with more than 40 doctors,

researchers and patients show.

Long-term complications-from chronic pain to malnutrition - appear to

be underreported. The central question of whether the surgery prolongs

life remains unanswered. Short-term death rates - typically 1 in 50

patients, to 1 in 100 or better - vary wildly among hospitals. Worries

are increasing about the field's rapid growth. Calls for more rigorous

study of the surgery's risks are getting louder.

In the past two years, patient deaths have prompted at least 10

hospitals in six states to suspend their weight-loss surgery programs,

the Post-Dispatch has found.

Some insurers are so alarmed they've stopped paying for the operation.

Dr. Barry Schwartz, former medical director and current vice president

at Blue Cross Blue Shield of Florida, said he considers weight-loss

surgery to be yet another discredited obesity treatment like

amphetamines or phen-fen, the drug cocktail pulled from shelves in

1997. That was why the insurer - the state's largest - dropped

coverage for the operation on Jan. 1.

" The history of obesity, unfortunately, " Schwartz said, " is that this

is a very vulnerable population that will leap on any bandwagon that

comes through. "

A booming business

The American Society for Bariatric Surgery (bariatric is from the

Greek for " weight " and " treatment " ) had 367 active surgeons in 2000.

Four years later, the number had jumped almost fourfold to 1,366.

" The interest from a surgeon's point of view is just going up

logarithmically, " said Dr. Snyder, a surgeon in Alaska. " A big

feature of it is economics. "

Weight-loss surgery is a top-paying specialty. An operation can cost

$15,000 to $50,000. Patients often are willing to pay their own way if

insurers say no.

And there is no shortage of patients. As many as 9 million U.S. adults

are at least 100 pounds overweight, making them big enough right now

to qualify for surgery. " We're just barely reaching the tip of the

iceberg, " said Dr. Norbert , a St. Louis weight-loss surgeon.

Hospitals have stepped up to meet the demand. In St. Louis, the

NewStart Center at St. ius Hospital started out eight years ago

competing mainly with just -Jewish Hospital. But the list has

grown over the years to include hospitals in the Missouri cities of

Columbia, Springfield, Kansas City and Joplin, and in Memphis, Tenn.,

Peoria, Ill., - even Mountain Home, Ark.

NewStart remains busy. Its three surgeons on average perform 43

bariatric operations a month - more than one a day - accounting for

nearly 20 percent of all operations at St. ius.

Elsewhere, entire hospitals have been turned over to doing just

obesity surgery. Chains of bariatric clinics with surgeons flying

between them have opened across the country.

One national chain, The Wish Center, offers a $500 referral bonus and

recently launched a new ad campaign. One TV spot shows a man talking

about the death of his morbidly obese friend Kim, who apparently did

not have bariatric surgery: " You see, I have cancer and I'm going to

die. Kim, she didn't have to. That's what really kills me. "

Some surgeons worry how all of this is changing the profession.

" The surgical field is just shooting itself in the foot, " said Dr.

Craig Albanese, chief of pediatric surgery at Lucille Packard

Children's Hospital in Palo Alto, Calif., which recently began

performing gastric bypasses. " These surgery centers and people are

cropping up all over. It's basically one big wallet biopsy. I don't

call it any more than that. It's deplorable. "

Closing the door

At the same time, at least 10 hospitals in six states have dropped

weight-loss surgery programs since 2003. The reasons were varied, and

some institutions restarted their programs after overhauls. But the

experience shows the risks involved in the rush to get into obesity

surgery, critics say.

In June 2004, the University of New Mexico Hospital in Albuquerque

shuttered its obesity surgery program, leaving the state without a

provider. The move followed at least two patient deaths and subsequent

lawsuits.

Iowa Methodist Medical Center in Des Moines stopped doing the surgery

in September after seven patients died in recent years. The hospital

blamed rising insurance costs for its decision.

In the Macon, Ga., region, one hospital curtailed the surgery and

three others stopped doing it, including Coliseum Medical Centers in

Macon. It closed its obesity surgery program for good in September.

That followed a three-week hiatus in December 2002 after a patient's

death. " It shook us up. It concerned us, " said Boggs, the

hospital's chief executive.

" Finally free "

Despite the field's problems, the surgery's popularity is easy to

understand: It does what patients can't. It is a diet enforced by

changes to the anatomy.

The most popular method is the Roux-en-Y gastric bypass. Using staples

and sutures, surgeons shrink the stomach from the size of a football

to a small egg. A portion of the intestinal tract is bypassed. The

result: Patients eat less food and absorb less of what they do eat.

Patients tend to lose about two-thirds of their excess weight in the

first two years. But few will ever be called thin. " You're not going

to come out of this looking like a supermodel, " said Dr.

Turkelson, chief research analyst at ECRI, an independent health

services research company in Plymouth Meeting, Pa.

ECRI last year reviewed more than 70 studies of weight-loss surgery.

It found the average patient, a 5-foot-4 woman at 275 pounds, weighed

about 190 pounds three years after the operation - still obese, but

much less so.

Assuming she survives. One percent to 2 percent of patients die during

or shortly after bariatric surgery, according to a health technology

assessment published last year. That translates into 1,400 to 2,800

deaths last year. An additional 10 percent to 20 percent of patients

develop complications, including life-threatening ones, according to a

federal review of multiple studies.

Those risks are worth it, surgery supporters say, considering obesity

increases the risk of developing heart problems, cancers and diabetes.

The operation has grown safer since it was first used in the late

1950s. But the procedure required decades of fine-tuning to gain

acceptance. In 1991, a federal advisory panel gave its conditional

blessing. The panel said the operation could be useful for certain

adults more than 100 pounds overweight. Still, the field failed to

take off.

Two things changed that. In the mid-1990s, doctors began using

laparoscopic tools. The minimally invasive surgical equipment reduced

operating risks. Then, in 1999, pop singer Carnie had her

weight-loss surgery broadcast live on the Internet.

Since then, - like celebrity patient Al Roker of the " Today "

show- has become the public face of the operation.

It was Roker's surgery that helped persuade , 43, of Du

Quoin, Ill., north of Carbondale, to have the operation at the same

time as his wife, e, 32. They are thrilled with the results.

" It's like you're finally free, " e said.

When they married in September 2001, she weighed 250 pounds.

weighed 360. The two of them struggled to get close enough

to share a wedding day kiss.

They wanted to change that. wanted to be free of his diabetes.

e wanted to have children, and she knew obesity affects fertility.

e had a gastric bypass in December 2003 at NewStart.

Her husband followed six weeks later.

A year afterward, they talked about their experience over a shared

Fisherman's Platter at Joe's Crab Shack in Fairview Heights. She had

lost 100 pounds. He was 115 pounds smaller and no longer needed drugs

to control his diabetes. They had re-sized their gold wedding bands to

fit their smaller fingers. But the rings were loose again.

Now, they can kiss with ease. " And it is wonderful, " e

said, beaming.

A worrisome view

From his surgical practice in the isolated environs of Anchorage,

Alaska, Snyder has a unique view on obesity surgery.

" Here in Alaska, we're seeing the complications of surgeries done in

the lower 48 states, " Snyder said in a telephone interview.

Patients who live in Alaska might travel out-of-state for obesity

surgery in search of a better price or a particular surgeon. But once

problems set in, they have few options. Only three surgeons in the

state are affiliated with the bariatric society.

In the past five years, Snyder has worked on 26 patients to correct

complications stemming from gastric bypasses done outside Alaska.

Snyder doubts the original surgeons ever found out.

" If I'm the surgeon in San Diego and operating on people and shipping

them to Wyoming, Oregon or back to Alaska, I probably don't have the

foggiest idea that these people are getting complications, " said

Snyder, 62, who grew up in Hannibal, Mo., and attended medical school

at the University of Missouri at Columbia.

Snyder is open about his record as a surgeon. He keeps detailed

statistics - the kind of numbers that insurers and the bariatric

society would love to see from all obesity surgeons. He can tell you

his operating death rate (less than 1 percent) and the complications

that developed - from massive blood loss to spleen tears to deep-vein

thromboses and hernias.

Snyder suspects that surgeons who don't track this information have

their reasons.

" They don't want to take the time and trouble to do it, No. 1, " he

said. " No. 2, they probably don't want to know the answers. "

More study could produce surprising results, Snyder said.

" We really don't know what we're doing. We think we do. But the more

you look at it and the more you study it, the more you come to the

conclusion that perhaps we really don't know. "

" I am not alone "

What insurers and doctors fear is a case like Ostroushko's.

Ostroushko, a mother from Eagan, Minn., had gastric bypass surgery on

Dec. 3, 2003, at a major medical center in Minneapolis. She was

morbidly obese, weighing more than 316 pounds. She also had a heart

condition and her cardiologist thought surgery might help.

Right away she suffered. She had chronic nausea and diarrhea.

Dehydrated, she was in and out of the hospital. Her intestines were

blocked and her stomach kept filling with fluid. She has been afraid

to go back to her original surgeon. Other doctors have refused to

treat her. She said she's been told her case is too complicated.

" If I could do it all over again, I wouldn't do it, " Ostroushko said

in an interview.

Ostroushko has recounted her experiences on a popular online message

board run by the Association for Morbid Obesity Support, an advocate

for surgery. The day after her one-year surgery anniversary she posted

an update: " I was so much better off heavier than I am now. I live my

life as an invalid, I cannot take care of my 4-year-old son on my own,

my marriage is so strained, we are financially drained, emotionally, I

am a wreck, physically, I couldn't be any worse off, unless I was dead. "

Her candor has earned her scorn, she said. Some people on the Web site

have accused her of scaring people who might benefit from the surgery.

Ostroushko believes others like her have been silenced by similar

pressure.

" I am not alone out there, " she said.

Pills and more pills

Long-term malnutrition may be the most common complication of gastric

bypass.

The body changes that hasten weight loss also open the door to

frightful problems.

Patients need to take daily vitamins and watch their diet to avoid

deficiencies. e stopped taking her twice-a-day,

vitamin B pill and within weeks noticed three fingers were numb. The

numbness spread up her arm. Alarmed, she called her doctor, who

ordered her to take her pills and to get a vitamin booster shot. The

numbness eventually went away.

Seemingly minor, vitamin deficiencies can morph into fatal

complications. For doctors, it presents a quandary: How do you get

patients to take their pills?

" They just don't want to do it. It's hard to believe, but it's true, "

said Dr. Walter Pories, a past president of the bariatric society.

In a study of 435 patients released last year, the Mayo Clinic in

Minnesota found that painful nerve damage developed in 16 percent of

weight-loss surgery patients - a significant number, according to the

study's authors. Symptoms ranged from tingling and numbness to severe

pain and weakness that left patients confined to wheelchairs.

The cause of the nerve damage: patients not taking their vitamins.

Study author Dr. Dyck, associate professor of neurology at the

Mayo Clinic, said the findings showed the need for intensive education

of patients before and after surgery.

A key question

Last year, the federal government launched its first multisite trial

of obesity surgery. The National Institutes of Diabetes and Digestive

and Kidney Diseases hopes to learn more about the operation's risks

and benefits by studying outcomes at six medical centers over the next

four years.

In December, an advisory group to the federal Medicare program

delivered an upbeat report on obesity surgery compared to nonsurgical

treatments. Now, Medicare is considering paying for the operation,

which could further fuel its popularity.

But the scope of the report's findings was relatively narrow, said

Shekelle, the report's author and the director of the Southern

California-RAND Evidenced-Based Practice Center.

Shekelle said that while the RAND report found surgery was more

effective than other tactics for treating the most seriously obese,

the same conclusion could not be drawn for people who were less

overweight but still morbidly obese. And while the surgery helped

resolve some conditions, like diabetes, it was not clear that patients

live longer than obese people trying other treatments.

This is a key question. Does surgery extend lives? Many in the obesity

surgery field have been eagerly anticipating an answer from the most

rigorous, ongoing weight-loss surgery study in the world - the Swedish

Obese Subjects study. But the study authors, who published an update

in December, have been silent on this matter.

" What I conclude is that there is no statistically-meaningful

difference, " Shekelle said. " If there was a strong difference either

way ... we would know it by now. "

Dr. Lars Sjostrom, the Swedish study's principal investigator, said in

an e-mail he expected the mortality question to be answered within two

years.

Almost nothing is known about whether bariatric surgery has a

measurable long-term impact on a patient's quality of life.

States crack down

Some states are doing their own studies.

In Massachusetts last year, public health officials ordered a

statewide review of the surgery's safety after noticing six deaths in

18 months.

" We recognized the misinformation out there in terms of risk, " said

Ridley, director of the state's Betsy Lehman Center for Patient

Safety and Medical Error Reduction, which oversaw the inquiry.

In North Carolina, Blue Cross Blue Shield tries guiding customers to

the best and most experienced surgeons, something it does for only one

other procedure: bone marrow transplants.

In Missouri, most standard plans offered by major insurers exclude

weight-loss surgery. Illinois insurers offer a range of coverage.

One of the most thorough surgery shake-ups occurred in Washington state.

It was set off by Dr. Jeffery , chief medical officer for

state Medicare, who was shocked by mortality statistics he received in

the summer of 2003.

The 30-day death rate for obesity surgery ranged from zero to 40

percent. In other words, some surgeons were losing four out of every

10 patients.

In August 2003, ordered an emergency halt to the surgery for

his agency's clients. State Medicare then asked for an in-depth

analysis of Washington's obesity surgeries. A clear relationship

emerged between the number of surgeries a hospital performed and

results: Hospitals that did fewer than 10 operations a year had a 12

percent death rate, while hospitals that did more than 100 had a rate

of 2 percent.

Coverage was reinstated last March, but with tough new restrictions.

Hospitals had to show they could do the surgery safely and follow up

with patients on a long-term basis.

The agency also limited who could get the operation, going far beyond

the widely adopted federal guidelines. Prospective patients had to be

between 21 and 60 years old. Simply being severely obese was not

enough. Patients also had to suffer from one of three conditions:

diabetes, the need for major joint replacement or a rare

weight-related condition like pseudotumor cerebri, which is excessive

pressure around the brain.

It was a radical solution. But justifies it as a way of

mediating " a need versus a want " for surgery. " We as the physicians

need to understand the needs, " he said. " We don't know the answers

yet. And when you don't know, you're cautious and conservative. "

Even many bariatric surgeons stung by the criticism recognize the

field's problems.

Dr. Harvey Sugerman, president of the American Society for Bariatric

Surgery, accuses insurers of " doing their darndest " to block access to

an operation effective at curing diabetes and perhaps easing other

weight-induced conditions. Comparing the risks of bariatric surgery to

the dangers of diet pills is ridiculous, he said.

But the bariatric society is moving in the same direction as insurance

companies and regulators.

" There are some bad apples out there, " Sugerman said. " We've got to

clean up our own act. "

Last year, the group set up a separate company to certify centers that

follow strict guidelines. Those that qualify expect to be designated

" Centers of Excellence " later this year.

The price of size 4

Sandy Pierce admits, quietly, that she regrets her decision. She is

troubled by the vitamin deficiency that hit her despite her diligence

in taking her pills and watching what she eats. " I did everything

right, " she said. " Why me? "

She still thinks the surgery is good for people who weigh 800 pounds.

But too often, she said, she hears from people 80 to 100 pounds

overweight who want the operation.

She plans to continue leading her support group. They need her to.

" I'm here to educate them and to tell them to take their vitamins and

eat the way they're supposed to, " Pierce said. " But am I going to

encourage them to have the surgery? No. "

Pierce had her original operation at a bariatric surgery chain in

Ohio. Her surgeon has moved on. She said she never told him about her

complications. He probably has no idea.

Now she is considering having one more operation. It would be to

reverse her gastric bypass.

" It's great to bop around at size 4 but at what cost? " Pierce said.

" It's like this is God's way of saying, 'You should've left your

anatomy alone.' "

Some milestones in obesity surgery

1966: First gastric bypass performed, at University of Iowa.

1991: Federal advisory group gives obesity surgery conditional

approval.

1990s: Use of minimally invasive surgery tools increases in obesity

operations.

1999: Singer Carnie has weight-loss surgery broadcast live on

the Internet.

2001: NBC weatherman Al Roker has gastric bypass.

2001: FDA approves silicone band implants around stomach to control

eating in adults.

2003: Obesity surgeries in United States surpass 100,000 for first

time.

2005: Implantable band for teens begins FDA trials at University of

Illinois at Chicago.

Reporter Todd C. el