Weight-loss costs: a critical look at gastric surgery.

Obese people who opt for weight-loss surgery incur increased odds of subsequent hospitalization and, in some groups, a substantial risk of death, say researchers who have investigated this burgeoning treatment. Even so, some of the scientists say, those risks may be justified.

Gastric-bypass surgery--which detours food around most of the stomach--and other weight-loss, or bariatric, operations usually mitigate numerous conditions, including diabetes, sleep apnea, and high blood pressure and cholesterol. Nationwide, surgery is an option for about 10 million severely obese people, says David R. Flum of the University of Washington in Seattle.

Five times as many women as men choose a weight-loss operation, usually after dieting and exercise fail, according to an analysis of hospital records by Heena P. Santry of the University of Chicago and her colleagues. They found that the surgical patients are primarily people from wealthy communities and who have private insurance.

Santry's team estimates that doctors performed 102,794 bariatric operations in 2003, up from 13,365 in 1998. More than 80 percent of the procedures were gastric bypasses.

Rates of immediate deaths and complications from weight-loss surgery stayed even during the years investigated, but average recovery time in the hospital decreased from 4.5 to 3.3 days, Santry's team reports in the Oct. 19 Journal of the American Medical Association (JAMA).

The operations nevertheless have substantial risks. David S. Zingmond of the University of California, Los Angeles and two colleagues found signs that gastric bypass increased the risk of serious health problems for several years. For example, 19.3 percent of California patients who had undergone the surgery returned to a hospital within a year. By comparison, only 7.9 percent had been hospitalized in the year before the surgery.

Hospitalization rates hovered around 15 percent or higher during the second and third years after gastric bypass, Zingmond's team reports in the same JAMA issue. Costs associated with the 3-year increase in hospitalization could amount to roughly half again the $25,000 price tag for the surgery, the researchers say.

Such costs might have already dissuaded insurance companies from readily sponsoring weight-loss operations for some patients, Zingmond says. Gastric-bypass operations in California peaked in 2003, before declining by nearly 15 percent in 2004, he notes.

In a third report in JAMA, Flum and other Seattle-based investigators examined surgery's risks among bariatric patients who receive Medicare. Those patients, who account for about 6 percent of bariatric surgeries nationwide, tend to be disabled by their obesity, Flum says. This might give them more to gain by surgery.

The researchers found that 2 percent of Medicare patients died within a month of surgery and 4.6 percent died within a year. Those death rates exceed comparable values for elective coronary-bypass and hip-replacement operations as well as rates in past studies of bariatric operations that were performed by well-practiced surgeons on select patients.

Among the Medicare patients, those who were male, older than 65 years, or had the surgery performed by teams with limited experience in bariatric procedures had the highest risk of dying in the first 3 months or year after surgery, Fluln's team found.

"It's not that we shouldn't do the operation," says Flum. "It's the only intervention that provides significant and sustained weight loss for obese individuals." But patients, doctors, and institutions that pay for health care, he says, must consider the risks in deciding who should receive an operation and where.