Preparing For Gastric Bypass
Getting ready for surgery requires work from doctors and the patient. Not everyone has access to good care.
Photo by Christopher Furlong/Getty Images
On a Friday morning in June, 2002, Charlie Weis, an offensive coach for the New England Patriots, checked into Brigham and Women's Hospital in Boston. He was nervous about his bariatric surgery scheduled for that morning, and he hoped no one recognized him. In a few hours, Weis, a self-described "pudge ball" through adult life,Â would wake up in the post-anesthesia care unit without a stomach and with a catheter inside his penis, a breathing tube down his throat, and a morphine pump and intravenous line in his hand.
He had tried every diet under the sun, and he was worried that his obesity would prevent him from getting a head coach's job in the National Football League.Â His father had died of a heart attack at age 56, and the younger Weis wanted to be around for his own children, one of whom was developmentally disabled.
Weis's first hours in recovery went well.
At around 6:00 pm, his surgeon was comfortable enough to go home for the night.
But early next morning, Weis felt worse. His chest felt heavy. The doctors suspected a blood clot in his lungs, an embolism, but a CT scan showed nothing. His intensive care nurse later testified that a large amount of blood was coming out of a stomach tube. A hospitalist gave Weis a blood transfusion.Â By Sunday morning,Â Weis was delirious. He developed a severe bacterial infection. He went into coma. On Sunday afternoon, surgeons pulled out his stitches, found an astometis had developed between his new, tiny digestive sack and his old stomach. Pools of congealed blood in his abdomen were a breeding ground for bacteria. Weis nearly died.
A few years ago, Weis sued the surgeons who treated him. After a lengthy trial, jurors found the doctors not guilty. Weis mostly recovered but he still experiences residual pain from the operation.
To this day, he remains obese.
His story has become a talisman for opponents of bariatric surgery, who say that it shows how even the relatively healthy--and Weis, despite being obese, was relatively healthy for a surgery candidate--can experience severe complications that doctors aren't prepared to deal with.
And these critics are correct, in a sense. Gastric bypass surgery is risky. It is especially risky if patients and surgeons think of it as a surgery, and nothing more.
This is what happened in Weis's case. It turns out that he had not received, because he did not ask for, a critical pre-surgical blood test that would have indicated an enhanced risk of internal bleeding. Because he was ashamed of the stigma he hadn't told friends about the procedure, so he did not have a community of support to make sure he went to all of his preoperative appointments. His doctors worked for one of the best hospitals in the world, but they communicated poorly with each other.
As I scanned articles about the trial, I couldn't help but compare Weis's experiences with my own.
For one thing, my surgeon insisted that I understand what I was in for, what I needed to do, and what could go wrong. He would not operate on me unless I had a support system to help me prepare and recover. He required no fewer than ten separate pre-operative tests and a written commitment that I would attend post-operative counseling for the rest of my life.
I didn't care much about the stigma, so I was happy, almost effusive, to explain to people why I would be missing several weeks of work. I bought books, looked up journal articles, joined support Web sites.
A few days before the surgery, at the surgeon's insistence, I visited the hospital. I met the nurses on the ward who would take care of me, and I spoke to recovering patients, including one who had, about 24 hours earlier, been operated on by my surgeon.Â I was encouraged to ask her, and did, what I needed to know...what I should ask the nurses...what I shouldn't forget to do.
By the morning of my surgery, I wasn't nervous. (My mother was nervous enough for both of us.)Â Â I knew that I couldn't control the steadiness of my doctor's hand, and I couldn't prevent a freak accident with anesthesia.Â But the surgery was not mysterious to me. I knew precisely what would happen.
I woke up, heavily sedated, with pressure cuffs around my legs, numerous tubes in orifices and through the skin, beep beep beeping of the heart monitor. Like Weis, there was an early sign that something was wrong. For one thing, my pulse was racing. That could be a sign of an embolism. I was wheeled down to the CT machine.
A scan found nothing. Every two hours, a nurse injected me with heparin and tested my blood. Aside from the heart rate, nothing seemed amiss. There was no sign of infection, no sign of bleeding. I asked a lot of questions and insisted, politely and firmly, that they be answered. I made sure that the ICU nurse stopped to think about whether there was a way to figure out whether my pulse rate was a sign of anything more serious.
Early the next day, a radiography nurse gave me a barium concoction to swallow. A continuous radiogram of my digestive system--my new digestive system--showed no leaks. My pulse rate was still higher than normal, but it was slower than it had been before.
A few days after I went home from the hospital, I noticed that my surgical incision, which had been remarkably mundane a mere 48 hours earlier, was suddenly crossed with bright streaks of red. It was warm to the touch. That meant it was infected. Fortunately, I had prophylactic antibiotics at home, and by the time I visited the surgeon the next day, the infection was ending.
I did make one mistake. My body had given me a signal, very early on, that an infection was brewing. Three nights after the surgery, I experienced a bout of chills. But I deliberately ignored it--I was too tired and in too much pain to make the trip back to the hospital.
So I did a lot differently, but I didn't do everything differently. My body was hardy, though, and my intensive preparation paid off.
The point here is not to suggest that Charlie Weis did anything wrong. Doctors make mistakes, and so do patients. Abdominal surgery is inherently risky, and infections, including minor ones like mine, are common. Gastric bypass surgery isn't a cosmetic procedure, even though many patients, Weis and myself included, had reasons other than health to want the surgery. It does not cure obesity. The month before and after the surgery were hard, time-consuming slogs, requiring endless patience from my employers and my partner and family.
Obesity is correlated with economic status. Most candidates for surgery, assuming their insurance companies won't pay for it, tend not to have the time or the money to get the procedure.
But a lack of social capital is the biggest reason why those for whom the surgery could grant a second lease on life are barely aware of the procedure.
A few years ago, the governing board for bariatric surgeons created a non-profit corporation that would independently evaluate and certify hospitals and surgeons for gastric bypass procedures. They set up fairly stringent criteria, including long-term outcomes, pre-and-post operative care, infection rates in hospitals and more. As you might expect, the facilities that are designated as "centers of excellence" and the surgeons allowed to operate in them charge more for the higher quality service.
More than 380 surgeons, including my own, now have the seal of excellence.
Like any professional community, bariatric surgeons tend to want to protect their territory. In recent years, general surgeons have started to do the procedure. They tend to charge less. On the one hand, this expands access to surgery. On the other hand, it means that poorer people or people whose insurance doesn't cover the full cost of weight loss surgery will find themselves under the knife of a less experienced surgeon. Richer patients--patients with more resources, income support--will find their way to the Centers for Excellence.
But, importantly, there is a fairly large correlation between the experience a doctor has in performing the surgery and the rate of major or minor complications. In general, it takes about 100 such surgeries for the major complication rates to settle down.
Outcomes remain better for specialist surgeons in part, I believe, because the specialists, especially those who've been certified as excellent, expand the pre-and-post operative treatment process so significantly.
This inherent inequality is, unfortunately, a normal part of our health care system, and no Congressional reform will change these incentives over the short term.
Patients must fend for themselves. Information--and rigorous questioning and gut-sensing--are even larger parts of their recovery.