Bariatric Surgery??

[RNtoDO]

I just recently watched this operation (gastric bypass) on tv and it seemed very cool. I was wondering if any surgeon after a general surgery residency can perform this procedure or do you have to do a fellowship?????

How is the pay in this (sub?) specialty??? Seems like it would be good, because you would assuredly remove their gallbladder after the weight gain as well??????

Anyone have any experience in this area they would like to share???

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[imtiaz]

i know they get sued the most. plus, you have to like operating on obese people, which is a lot more challenging. maybe others can contribute as to what the pay is, etc. i just know that i wouldn't do it for a living.

 

[DrMom]

They're doing tons of these surgeries around here. (in the fat midwest) They are basically all high-risk surgical patients because of their weight & some cannot even have the appropriate pre-surgery tests (they prefer to have things like CTs before sx to rule out other problems) because of their size. (generous habitus as most of the radiologist I've been rotating with politely put it)

That said, it can really help some people if they are also willing to make the lifestyle changes. I believe that it is general surgeons who are doing the procedure, but I haven't really investigated.

 

[supercut]

there are a few unoffical fellowships. But compeleting a gen surg residency is enough (for now, anyway)

These pts can be a real pain to deal with. Many have lots of psych issues. And the complications of the surgery can be very bad. Most residents hate it because the pt population is more like the psych population.

But if it floats your boat, more power to you!

 

[Winged Scapula]

I just recently watched this operation (gastric bypass) on tv and it seemed very cool. I was wondering if any surgeon after a general surgery residency can perform this procedure or do you have to do a fellowship?????

How is the pay in this (sub?) specialty??? Seems like it would be good, because you would assuredly remove their gallbladder after the weight gain as well??????

Anyone have any experience in this area they would like to share???

Here in fat Pennsylvania, we do a lot of them as well. Most general surgeons are trained to do them, but many elect not to - largely because of the incredible pre- and post-surgical problems these patients face. Without a good interdisciplinary team, many patients are doomed to fail a GBP and some practitioners do not have the resources of a dietician, psychiatrist, etc. to help set up a practice.

However, there are Bariatric fellowships (we have one at Hershey) for those interested in gaining more experience. The subspeciality is considered to be well paid but again, you pay for it in the high complication rate and post-operative management these patients require.

 

[pikachu]

I have heard secondhand of a general surgeon in Florida who is pulling down $2 million a year doing exclusively bariatric procedures. There was a case study recently (August) in the New England Journal which reviewed this procedure and quoted a mortality rate of < 1% and a complication rate of 10%. Here is the link, it's a good article: http://content.nejm.org/cgi/reprint...6234806020_8155&FIRSTINDEX=0&journalcode=nejm

I don't know if I would envy working with this patient population despite the $$$. In a rotation at a primary care practice I recently saw a patient who deliberately gained 27 more pounds to get her BMI up over 40 so that her insurance company would pay for her gastric bypass surgery (I guess the company is partially to blame here as well.) Completely uncontrolled type II diabetes with peripheral neuropathy, and never checked her blood sugar because she was afraid it would be high. She wouldn't quit smoking, either, because it helped "calm her nerves." 👎

 

[Celiac Plexus]

bariatric surgery = psychiatric surgery

I think it's a sad commentary on the general physical state of our nation's populace when 30-40% are obese and 60% are "overweight". And the projections for the next 20 years are abysmal.

That we now have a cottage industry of "bariatric" surgery popping up is dismaying to me.

That said, it appears that we will not be able to stop people from overeating and underexercising. Gastric bypass and variations of this oeration seem to help people lose weight. A significant portion will "fail" the surgery i.e. they will gain back the weight a couple of years down the road that they lost immediately post-op. And, once you perform bariatric surgery on someone, you will own them for life and will potentially deal with their weight loss issues forever. It's not like taking out a gallbladder...

The mortality is very low. The morbidity and frustration levels are higher... I have scrubbed in on a couple of gastric bypass "re-do"s as well as a few leaking anastomoses. At about hour 2, when you're elbow deep in pannus, and can barely see the field past the king-sized deavers, you have to wonder if all those super-sized meals, and twinkies were worth the aggravation: the patient's and yours.

A good interdisciplinary team is essential, and it is my humble (and admittedly highly inexperienced) opinion that if you are doing this kind of surgery without an extensive interdisciplinary team to help the patient, then you are setting the patient up to fail.

The money is pretty good though. Which may explain why *some* in the field are really pushing for this kind of surgery. More and more fellowships are starting up, although there appears to be an issue of accreditation. If you completed a general surgery residency in a fatty area of the country (apparently everywher now), then you will be able to do these surgeries upon graduation.

 

[Pir8DeacDoc]

As I understand it, gastric bypass really got going in its current form here at my med center under Dr. Walter Pories in the late 70's early 80's. Therefore the sometimes heard term "Greenville Gastric Bypass". Needless to say we still do plently of these procedures and my surgery rotation was full of them. You all are correct that the patients are "unique" and present with their own set of problems. As a tertiary care facility we see the worst of the lot and I can attest to what others have said about the high risk nature of the procedure. It's not a good idea to have a BMI of 95 and undergo an operation. As it relates to the original question, our medical center has one guy a year who has just completed GS residency that spends the year working with our Gastric bypass team. Not sure that it's a formal fellowship, but he does seem to be learning a lot about how to do them. Best of luck to you.

 

[Winged Scapula]

I have heard secondhand of a general surgeon in Florida who is pulling down $2 million a year doing exclusively bariatric procedures. There was a case study recently (August) in the New England Journal which reviewed this procedure and quoted a mortality rate of < 1% and a complication rate of 10%. Here is the link, it's a good article: http://content.nejm.org/cgi/reprint...6234806020_8155&FIRSTINDEX=0&journalcode=nejm

I don't know if I would envy working with this patient population despite the $$$. In a rotation at a primary care practice I recently saw a patient who deliberately gained 27 more pounds to get her BMI up over 40 so that her insurance company would pay for her gastric bypass surgery (I guess the company is partially to blame here as well.) Completely uncontrolled type II diabetes with peripheral neuropathy, and never checked her blood sugar because she was afraid it would be high. She wouldn't quit smoking, either, because it helped "calm her nerves." 👎

The patient population is very difficult to handle. Perhaps it goes without saying, but morbidly obese patients often have multiple psychological issues and can be very needy. As noted above, once you operate on these patients, you own them for life. Many of my most frustrating outside patient calls as an intern were from pre or post op GBP patients. Crying, yelling, and generally unhappy people who perhaps didn't understand the lifestyle changes the surgery required or the lengthy recovery period. Carnie Wilson has a lot to explain for making it look so easy. We have a wonderful interdisciplinary program here but patients still go through the surgery not really understanding how it will change their lives, how rotten they can feel after surgery, what the potential complications are, and how they can sabotage the surgery by eating too much and/or too much of the wrong thing.

You would have to pay me a pretty penny to do this surgery as a life's work.

 

[Sir Jun]

We do a lot of laparoscopic Roux en Y's here in Syracuse, and they have a nicely developing multidisciplinary program here with nutritionists, PT's, exercise, psych evaluations, etc.

I believe that it is a worthwhile operation; take for example that one can usually cure patients of diabetes within days (this generally happens in around 80 to 85% of patients according to most studies).

But, unlike what someone said earlier in the post, the procedure is very risky. The literature generally reports a mortality for the laparoscopic version somewhere around 0.5%, which is obviously 1 in 200. Many patients do not appreciate this. And most surgeons feel that the actual mortality is greatly under-reported, and probably falls closer to 2%. Also, the laparoscopic version generally is possible only for the "healthier" and "thinner" of this patient population. Those with BMI greater than 60 generally are not candidates. This shifts a burden of sicker heavier patients to those surgeons who only do open-GBP's.

So yes, it's a tricky field with needy patients, but the patients are among the most grateful I've ever seen. Another falsehood is that most patients gain the weight back. This is untrue, especially if the patient is in a multidisciplinary program and they receive good follow-up *and* they were properly selected for surgery in the first place. The patients can beat the surgery by drinking milkshakes all day, but most don't do this. In fact, Roux-en-Y GBP is, I think, the only weight-loss modality in existence that I'm aware of that actually has good long term results (maintained ~50% excess body weight loss at 15 years post-op according to most studies that I've read). Some studies have actually shown decreased mortality among patients who've received the surgery compared to a cohort that has not received GBP (I think it was by Mories et al, but I'm not positive).

Anyway, interesting stuff that will be a serious element of surgery (until a pill is invented, which I feel is not *too* far off, along the lines of a ghrelin inhibitor, etc.)

Just my two cents.

Dan

 

[njbmd]

Hi there,
One of the best bariatric surgery programs in the country is at the University of Virginia under Bruce D. Schirmer, MD. He has a very detailed program for these patients that lends itself to excellent long-term results. There is a very long waiting list to get into the preliminary aspects of Schirmer's program. Schirmer would be the first to tell you that bariatric surgery is but one tool in the treating obesity. There are others. He operates with two Minimally Invasive Fellows who become adept at this very challenging surgery.

Laparoscopic Roux-en-Y gastric bypass is the most promising of the techniques so far. This procedure has a very steep learning curve but it can be mastered by most any general surgeon who is willing to put in the time. Again, the surgeons with the best success rates are those who have the most experience (as with most procedures). Complications are devastating and the patients can have co-morbidities that make this surgery extremely high risk.

Gastric bypass surgery can be overcome by some patients and the all of the lost weight can be gained back. There are also issues of performing gastric bypasses in teens that need to be addressed. Having loads of experience working with Schirmer and his team, I can say that gastric bypass patients are a challenge in many aspects but patients who successfully lose weight, lose insulin and are no longer hypertensive are very rewarding. Kimberly's article is a good one so check it out.

njbmd 🙂