Bariatric surgery

[epsilonprodigy]

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Apparently my institution does a fair amount of bariatric procedures. This seems really interesting to me, but I'm wondering why the fellowship is said to be so non-competitive. It seems like the hours would be sweet, the work would be pretty gratifying in most cases....so, what's the catch? Is it really just the "ick" factor, or are people worried they'll be made obsolete by a pill?

Anyone with experience in this field, do tell: what's a typical day like? What are the best and worst parts of the job? (Insert anything else this MS-2 may not be thinking of....?)

 

[Winged Scapula]

1. bariatric patients
2. bariatric patients
3. bar...(you get the point)
4. declining insurance coverage for procedures
5. high litigation specialty; may require rider on malpractice policy
6. repetitive nature of cases if you don't do general surgery as well
7. need hospital/office with euipment and infrastructure for bariatrics (dietician, psych evaluation etc),
8. not "sexy" like other specialties

I suspect many GS residents have had bad experiences with bariatric patients which makes the field unappealing.

FWIW, I actually liked the laparoscopic Roux-en-Y gastric bypass surgeries but the patients were very difficult to deal with (and that's saying a lot coming from someone who elected to do breast surgery given the difficulty of that patient population LOL).

 

[epsilonprodigy]

No kidding, I wouldn't have guessed that this was a high-litigation specialty. I just became curious about it because our surgical clerkship director, who loves to come and chat with us, does a high volume of the Roux-en Y procedure. What is so difficult about bariatric patients? Noncompliance/relapse?

 

[Asperphys]

I agree that Bariatric surgery is very cool from a technical standpoint. But the patient population can be off putting.

To start with, they have a lot of comorbidities associated with obesity. You could easily have complications from their DM II, heart disease, OSA etc even before you make the first incision.

And I'm not sure if you'd call it noncompliance or relapse but most do not maintain weight loss of more than 50% of their excess (400lb guy dropping to 300lbs is considered typical). That means, they're still overweight if not obese (but at least no longer super morbidly obese). The most successful had discipline and stuck to a lifetime committed to exercise and eating right. They're the minority. At the other extreme you have another minority of patients who managed to gain weight despite the surgery because they adapted to the smaller stomach and malabsorptive anatomy by eating chips and drinking sweet tea all day.
Simply put, the majority lose some weight but will not be entirely healthy unless they also change their lifestyle. But it's very hard for them to do this because the surgery makes them hungry all the time.

This might be a reason why bariatric surgery is less than satisfying. You do not cure obesity entirely this way. After a lifetime of eating tons of the wrong kind of food, after the surgery the patients crave this food and can totally negate the RYGB by eating small portions of the same crap more often. If you can rewire their brains at the same time, so they don't have this urge, that would be perfect.

There are also post surgical complications that might be unavoidable given that the techniques and technology are still evolving. Strictures, leaks, internal hernias, fistulas etc happen and they're a pain to deal with.

So combine serious complications in very unhealthy patients with constant hunger and unrealistic expectations of weight loss from bariatric surgery, and you might get lawsuits.

 

[redbeans]

I would argue that Minimally Invasive Surgery/ Bariatrics is NOT an uncompetitive fellowship given that only 2/3 of applicants matched for the 2014-2015 cycle. Very few spots went unfilled. I know that doesn't answer all my thoughts on Bariatrics, just wanted to dispel the myth that the fellowship is an easy match...

 

[Winged Scapula]

I would argue that Minimally Invasive Surgery/ Bariatrics is NOT an uncompetitive fellowship given that only 2/3 of applicants matched for the 2014-2015 cycle. Very few spots went unfilled. I know that doesn't answer all my thoughts on Bariatrics, just wanted to dispel the myth that the fellowship is an easy match...

Who said it was an easy match?

 

[SLUser11]

I would argue that Minimally Invasive Surgery/ Bariatrics is NOT an uncompetitive fellowship given that only 2/3 of applicants matched for the 2014-2015 cycle. Very few spots went unfilled. I know that doesn't answer all my thoughts on Bariatrics, just wanted to dispel the myth that the fellowship is an easy match...

Please provide links to these stats. Classically, MIS was not a very competitive fellowship, match rates were very high for US allopathic residents, and there were a lot of open spots every year. Since I advise people on this all the time, and I'm technically faculty for an MIS fellowship, I need to know where to find this stuff.

I guess I'm not surprised, though, as popularity for fellowships is changing. For instance, plastic surgery was traditionally a very difficulty fellowship to obtain, but due to 1) a change to a 3 year fellowship and 2) watering down of the applicant pool due to the more accomplished students entering integrated residencies, it has become much more attainable in recent times.

 

[dpmd]

1. bariatric patients
2. bariatric patients
3. bar...(you get the point)
4. declining insurance coverage for procedures
5. high litigation specialty; may require rider on malpractice policy
6. repetitive nature of cases if you don't do general surgery as well
7. need hospital/office with euipment and infrastructure for bariatrics (dietician, psych evaluation etc),
8. not "sexy" like other specialties

I suspect many GS residents have had bad experiences with bariatric patients which makes the field unappealing.

FWIW, I actually liked the laparoscopic Roux-en-Y gastric bypass surgeries but the patients were very difficult to deal with (and that's saying a lot coming from someone who elected to do breast surgery given the difficulty of that patient population LOL).

Breast patients are difficult in a way that is easy to empathize with and generally rational at the very least (not wanting to have messed up looking boobs is something everyone can understand, and the ones whose first instinct is the overkill "cut them both off" strategy is also something that I bet most people can understand even if they don't agree with). Bariatric patients are a whole other category. They see the weight loss surgery as some magic bullet wherein they need make no lifestyle changes but they will suddenly be a healthy weight with a great figure. When reality disappoints them it is easier to blame the docs than look to themselves. Plus, anything you do on a really big person just sucks that much more (swimming through a sea of fat just to get to the fascia can sometimes take more time the the surgery itself-like if you are just doing an appy, plus then it is hard for them to get up after so more chance of complications and a longer hospital stay).

 

[FliteSurgn]

I haven't been on this forum FOREVER! Not sure how I ended up here today, but here's my 2 cents.

About 15%-20% of my practice is bariatrics and I love it. I had a strong interest in bariatrics right away because I loved the idea of doing those complex operations through the scope. And along the way I realized it's very rewarding to see patients become happier and healthier as you follow them through their weight loss journey. I perform the full spectrum of laparoscopic bariatrics...bands, RNY, and sleeve gastrectomy. I do a fair amount of revisional surgery...like bands over old open bypasses, conversions of old open VBGs to RNY gastric bypass, etc....all done laparoscopically. I also do all of the endoscopy needed on any of the bariatric patients at my main hospital...including interventional stuff like stricture dilatation and intraluminal stenting.

The operations themselves can be technically demanding, especially on males and the massively obese (BMI > 70). However, I like the challenging cases, sometimes to the chagrin of my PA. Bariatrics has evolved a lot since I did my first open gastric bypass in residency and the complication rates have fallen dramatically. A lot of this has to do with regionalizing these operations to places and surgeons that have an active interest in improving the care of the obese patient. Despite the litany of comorbid conditions we face in these difficult patients, the gastric bypass mortality rate in the US currently averages around 0.2%....that's the same as the mortality rate after a lap chole!

I agree that reimbursement has gone down over the last 10 years for these operations. However, that's true of most things as they go from new and novel to mainstream. Outside of Medicare, Medicaid, and Tricare, these operations still pay very well...more so if you are efficient and good at what you do.

Unlike a poster above mentioned, I argue that weight loss failure is more of a rarity than the norm after surgery (excluding non-compliant band patients!). And, comorbidity reduction (or elimination) is very durable. Diabetes resolution/remission rates after a gastric bypass are between 80-90% and it stays gone.

 

[thedrjojo]

I would argue that Minimally Invasive Surgery/ Bariatrics is NOT an uncompetitive fellowship given that only 2/3 of applicants matched for the 2014-2015 cycle. Very few spots went unfilled. I know that doesn't answer all my thoughts on Bariatrics, just wanted to dispel the myth that the fellowship is an easy match...

Anecdotally, I'm going to agree with this... In my program, I've seen a shift since entering that MIS has become the go to fellowship... My intern year we sent none into MIS, this current class of pgy4s (which would have been my year if I didn't go into the lab), at least 4 of the 10 (before anyone says anything, I know I've said we have 8 per year, but due to imbalance in lab residents, next year there will be 10) are doing MIS, including people with 2-3!!! years of research. It's definitely a field moving up.

But, there are a large pool of programs, each really unique, so choose wisely for yourself.

 

[Dr Tony T. Chopper]

After hearing Gawande talk about gastric bypass as it was back in 2003, it is amazing to hear how far it has come since then from a surgeon like yourself.

I haven't been on this forum FOREVER! Not sure how I ended up here today, but here's my 2 cents.

About 15%-20% of my practice is bariatrics and I love it. I had a strong interest in bariatrics right away because I loved the idea of doing those complex operations through the scope. And along the way I realized it's very rewarding to see patients become happier and healthier as you follow them through their weight loss journey. I perform the full spectrum of laparoscopic bariatrics...bands, RNY, and sleeve gastrectomy. I do a fair amount of revisional surgery...like bands over old open bypasses, conversions of old open VBGs to RNY gastric bypass, etc....all done laparoscopically. I also do all of the endoscopy needed on any of the bariatric patients at my main hospital...including interventional stuff like stricture dilatation and intraluminal stenting.

The operations themselves can be technically demanding, especially on males and the massively obese (BMI > 70). However, I like the challenging cases, sometimes to the chagrin of my PA. Bariatrics has evolved a lot since I did my first open gastric bypass in residency and the complication rates have fallen dramatically. A lot of this has to do with regionalizing these operations to places and surgeons that have an active interest in improving the care of the obese patient. Despite the litany of comorbid conditions we face in these difficult patients, the gastric bypass mortality rate in the US currently averages around 0.2%....that's the same as the mortality rate after a lap chole!

I agree that reimbursement has gone down over the last 10 years for these operations. However, that's true of most things as they go from new and novel to mainstream. Outside of Medicare, Medicaid, and Tricare, these operations still pay very well...more so if you are efficient and good at what you do.

Unlike a poster above mentioned, I argue that weight loss failure is more of a rarity than the norm after surgery (excluding non-compliant band patients!). And, comorbidity reduction (or elimination) is very durable. Diabetes resolution/remission rates after a gastric bypass are between 80-90% and it stays gone.

 

[TypeADissection]

One of my chiefs my intern year matched MIS. It didn't sound like it was a you're-a-warm-body-please-sign-here-and-when-can-you-start kind of match. But the beauty of general surgery, and it is beautiful, is the variety. There are so many different avenues to pursue. The expectations placed on us to master a wide volume of material and to think through different complex scenarios is pretty cool. For me personally, I'm not a big fan of bariatric cases and it's not even close how much I hate scrubbing bypasses. Gastric sleeve? OK. RNYGB? Shoot me in the face. I'd rather scrub a fem-distal. But that's the beauty of all this. You'll get in there, learn how to use some cool instruments, get better with your lap skills, etc. Clinic is rewarding though. You see these patients months or years after surgery and they look great, they feel great, they've made meaningful changes and are genuinely grateful. Then you'll also get consults in the middle of the night because someone who has a gastric band decided to inhale a bucket of fried chicken and feels nauseated. Take it all in stride. Always something to learn. Cheers.

 

[VPDcurt]

https://fellowshipcouncil.org/wp-content/uploads/2012/02/Match-Statistics-for-Web1.pdf