WEEKLY HEALTH BULLETIN September 18, 2009


GASTRIC BYPASS SURGERY COMES UNDER FIRE: SUDDEN LOW BLOOD SUGARS LEAD TO WEIGHT REGAIN

With the rising tide of obesity in this country, hospitals are doing a land office business in gastric bypass surgeries. Gastric bypass surgery makes the stomach smaller and allows food to bypass part of the small intestine. Because you feel fuller sooner, you eat less. Bypassing part of the small intestine means fewer calories are absorbed. This causes weight loss. Recent studies suggest various benefits along with weight loss, including normalization of blood sugar level and a “cure” for diabetes.

LAND OFFICE BUSINESS

Bypass surgeries have skyrocketed in the last few years. An estimated 220,000 gastric bypass surgeries were performed in 2008 at an average cost of $25,000 each — $5.5 billion health care dollars.

A LONG LIST OF ADVERSE EFFECTS

The procedure has risks. Adverse consequences include death (0.5% to 2.0%), blood clots in the legs, incisional hernia, iron deficiency anemia, vitamin B-12 deficiency, vitamin D deficiency, dehydration, gallstones, bleeding stomach ulcers, intolerance to certain foods, kidney stones, low blood sugar, body aches, flu-like fatigue, feeling cold, dry skin, hair thinning and hair loss and mood changes such as depression. This last can be difficult to treat since it often is caused by the changing role of food in the lives of people who have had the operation. Not surprisingly, malpractice lawyers are now busy marketing their services to bypass patients who experienced a bad outcome. No comment.

A NEW PROBLEM

Add another problem to the list. Many patients develop late, unrecognized low blood sugars that can result in grazing and other “maladaptive eating behaviors” (e.g. overeating) that result in undesirable weight regain. After surgery, insulin levels spike to abnormally high levels after eating. This causes rapid emptying of their surgically created pouch. Low blood sugar, hunger and overeating ensues. Patients considering a second “revisional” surgery because of unexpected weight regain (average 25 pounds) reported symptoms suggesting low blood sugar.

BLOOD SUGAR DROPS QUICKLY AFTER EATING

Sixty three patients were given a glucose tolerance test at an average of 4 years out after their surgery. This involves measuring a fasting glucose level and giving 100 mg of a sugar water formula. Blood sugar levels are then measured at 1 and 2 hours. A full two-thirds of all subjects exhibited a rapid blood sugar surge at one hour, followed by a precipitous drop at two hours. Interestingly, all but six subjects had normal fasting blood glucose levels, which calls into question the usual method by which “surgical cure” or “diabetes cure” is currently being measured.

Dr. Mitchell S. Roslin conducted this interesting study at Lenox Hill Hospital in New York City and reported on it at the recent meeting of the American society for Metabolic and Bariatric Surgery. Dr. Roslin was quoted as follows:

“I think it’s time to reconsider. I actually believe that vertical sleeve gastrectomy and duodenal switches that are not severely malabsorptive will be the best operations in the future”.

The above study was performed on patients who had the common “Roue-en-Y” procedure that does create severe malabsorption problems that require careful post –op lifelong nutritional attention. Dr Roslin has ties cited as “potential conflicts of interest” with Coviden AG, C.R. Bard Inc., Valen Tx Inc., Scientific Intake Ltd., and VentralFix Inc. . . . quite a list.

Presumably Dr. Roslin’s corporate affiliations are with companies involved with the new procedures. Fair enough.

IS ALL THIS MONEY WISELY SPENT?

My problem is not with Dr. Roslin’s preference for what sounds like a safer, more advanced procedure. Nor is it with gastric bypass surgery itself. The important question is whether a large portion of the $5 billion plus spent last year could have been put to better use. For example, a few billion dollars could pay for any number of hospital associated nutritional and fitness centers along with the professional staff required to run them. The liberal funding of this expensive, risky procedure is just another example of the perverse incentives in our health care system driving costs through the roof. Most people who have this surgery could have been treated without surgery, had sufficient resources been applied beforehand, rather than afterwards.

Of course, why should we be surprised at any of this? In this country, we don’t have a health care system; we have a health care market. Until we overhaul both the way we pay for health care and how we actually practice medicine, don’t expect any of this costly madness to change any time soon.
Reported in Internal Medicine News 9/1/09

Alan Inglis MD
American Country Doctor

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