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| How to Choose the "Right" Bariatric Surgical Center by Bradley J. Needleman, MD When Nancy Davis turned 50, she hurt so badly that she was not sure she wanted to live to see age 52. Davis, who had been overweight most of her life, was 5’6” and weighed 287 pounds. “My knees and back hurt; I was in so much pain that I could barely move,” said Davis. “I had got to the point that I couldn’t go to the grocery store or run the vacuum. My husband and I had stopped going to restaurants, because I could not fit into the booths.” Davis said she had tried several traditional weight-loss programs and had lost 100 pounds twice—only to gain the weight back. For her, weight-loss surgery was a last resort. To educate herself, Davis began reading books and magazine articles about bariatric surgery and scoured the Internet. She also launched a search to find a surgical center in central Ohio, where she lived. “Based on my research, I knew that weight-loss surgery would change my whole life,” said Davis. “I wanted to find a facility that would not only help prepare me for the surgery from a psychological standpoint, but would provide the ongoing support I would need long-term.” Davis faced the same challenge that thousands of Americans encounter every year—how to find the right weight-loss surgery center to meet her specific needs. With the number of bariatric surgeries performed each year increasing from 30,000 in 2000 to an estimated 150,000 in 2005, the number of facilities performing this type of procedure has increased dramatically. Surgical centers range from small clinics that specialize in bariatric surgery to comprehensive programs that may be part of larger hospitals—which makes the selection process a challenge. The following are factors to consider when evaluating weight-loss surgery centers and the services they provide. Surgical Procedures Performed If you are considering weight-loss surgery, you have probably researched the various options available and determined the type of procedure you prefer. You will then want to find a facility that performs that type of procedure. The facility’s size and the experience of its surgeons will likely determine the types of procedures performed. A comprehensive program that is part of a hospital, for example, is more likely to offer both open and minimally invasive procedures. Individual surgeons may likewise prefer to perform certain procedures. A woman recently contacted me about a facility she was working with in Boston. She indicated she felt very comfortable with her surgeon but was concerned that he performed gastric bypass as an open procedure rather than as a laparoscopic procedure, which she preferred because of the shorter recovery time. She asked whether she should try to talk the surgeon into performing the procedure laparoscopically, or if she should find another surgical center.  Because she felt so comfortable with her surgeon, I advised her to allow him to perform the procedure the way he preferred, since he was obviously more experienced with that technique. If she was determined to have a laparoscopic bypass, however, I recommended that she seek another facility or request another surgeon since it is always best to have the surgeon perform the procedure(s) for which he or she is best qualified.Even though you have the right to request a certain procedure, keep in mind that the type of surgery performed may depend on your physical condition and the potential for complications. You should always discuss any questions or concerns with your surgeon. Pre- and Post-Surgery Support Weight-loss surgery is more than an operation; it is a total commitment to improving your health. You must learn to cope with the stressors that trigger your desire to eat. You will also have to learn to choose the right foods to meet your body’s nutritional requirements and to eat smaller meals more often to satisfy your hunger and to maintain your energy levels. In addition, you will want to explore the possible personality and relationship changes that may result from your weight loss. Because successful long-term weight loss will depend on your ability to make a drastic change in your lifestyle, you will probably want to choose a facility that offers both pre- and post-surgery counseling. During pre-surgery counseling, a dietitian will likely review the usual diet and will discuss the body’s nutritional needs after surgery. Sessions with a dietitian and/or psychologist will help you examine past dieting successes and failures and will allow you to review life experiences about how your weight affected the choices you made. Davis said the details she learned during counseling and support sessions helped her understand some of the changes she would have to make in her lifestyle. The sessions also made her feel that she was not alone; others were facing some of the same problems. “Even though I had a general understanding of what to expect, I had very little knowledge of the details,” said Davis. “I did not know that I could no longer gulp water after the surgery and that I would have to sip it for the rest of my life. It was comforting to hear from others that I would be able to eat at restaurants again and that losing my hair was normal.” Davis has shed 164 pounds and now works out 90 minutes a day. She said the support group she attends helps keep her motivated. “Because we have both professional speakers and testimonials from patients, I feel like I receive guidance at both levels,” said Davis. “If I had not participated in a support group, I would never have known that after the first year my appetite was likely to come back two-fold. I also would not have understood how important it was to exercise to keep the weight off.” Since her surgery in 2002, Davis participates in a monthly support group and has an annual follow-up visit with her surgeon. She also regularly consults with a nutritionist. “When I was considering weight-loss surgery centers, I decided not to go to a small clinic in another city because it provided no support before or after surgery,” said Davis. “I think few people have the willpower and the knowledge to successfully lose the amount of weight they want to lose—and keep it off—after surgery without outside support.” Some programs recommend that family members attend some support group meetings so they know what to expect. Many programs offer support groups and follow-up visits with professionals free of charge, although some may charge for these services. A Track Record of Success The Internet is a great resource for researching weight-loss surgery centers. Most facilities have a Web site that describes their program, surgical team members and their credentials, the types of procedures performed and patient results. Many facilities also offer free seminars, which often include a facility tour and the opportunity to ask questions of a surgeon and other professionals. When considering a specific facility, make sure that all surgeons are licensed and board-certified. You will want to inquire about any specialty training a surgeon has received or fellowships they were awarded for bariatric surgery. You should also determine the number of procedures individual surgeons have performed and the total number of surgeries performed at the facility each year. Don’t be afraid to ask about the facility’s mortality and leak rates. Although the risks associated with weight-loss surgery will vary depending upon the individual, the risk of death is generally .5 to 1 percent. Death usually results from a pulmonary embolism or a gastrointestinal leak. The latter can occur when a complete seal does not form where the bowel and stomach are connected or stapled, which results in the bowel contents leaking into the abdomen and can cause a serious infection. On average, leaks occur in about one percent of weight-loss surgery patients. Make sure you find out how long the surgical facility has been in operation. You will want a facility that has performed weight-loss surgery for a number of years and has the services and support in place that you will need for ongoing success.  Facility Services and AmenitiesBecause of the complications often associated with obesity (including diabetes, hypertension, cardiovascular disease, breathing problems and liver disease), weight-loss surgery is potentially a high-risk procedure. If you have other health problems, such as those mentioned above or even severe sleep apnea, you should consider having the surgery performed at a facility that has an intensive care unit and heart and lung specialists available 24 hours a day. You should also determine whether the facility can physically handle obese patients. Does the facility have beds, chairs, transport stretchers and radiology equipment to comfortably accommodate you? What about the size of the bathroom facilities? You should even ask about patient gowns, which should fit and close in the back. Insurance One of the main reasons patients decide not to have weight-loss surgery is because they encounter problems with their insurance companies. Make sure the facility you are considering will accept your insurance and that your insurance provider will pay for the facility’s services. You should also consider choosing a facility that will work with the insurance company on your behalf to gain any pre-approvals that are necessary. While most large insurance plans will cover weight-loss surgery, some smaller plans will not cover the procedure or will only pay for certain types of surgery. Ask whether the facility you are considering will arrange for insurance approval and pre-certification of the surgical procedure and hospital stay.  If you are presently looking for a job and think that you may want to have bariatric surgery in the future, you should determine if the potential employer’s insurance will cover the surgery. With the number of procedures performed each year increasing so dramatically, many insurance providers are choosing not to pay for the procedure because of the costs involved. If you are on Medicare or Medicaid, you will want to confirm that the surgical facility accepts these plans. Most surgical facilities offer a self-pay option for patients whose insurance will not cover the procedure.Physician Rapport Since weight-loss surgery is potentially a high-risk procedure, it is important that you feel comfortable with your surgeon. You must trust the individual and feel confident in his or her ability to perform the procedure and to provide the care you will need after surgery. If you want a minimally invasive operation, make sure the surgeon you are considering has extensive experience performing that procedure. According to Davis, when she was considering surgical weight-loss centers, it was important for her to find a surgeon who would take a personal approach to what she considered a very personal problem. “I was not interested in having my operation performed by a surgeon who was just doing the procedure to make money,” Davis said. “I wanted someone who cared about my health and welfare and wanted to help me and other obese individuals who could not help themselves.” The “Right” Choice Selecting the “right” facility to perform your weight-loss surgery—and to support you after the procedure—is critical to losing weight and keeping it off. Like many patients who have decided to have weight-loss surgery, you are probably anxious to have the procedure performed so you can begin dropping the pounds. I recommend, however, that you take the time to thoroughly research the facilities you are considering, ask questions and talk to former patients. Weight-loss surgery is a life-altering event. The better prepared you are for the resulting, inevitable changes, the more likely you will be to succeed in the months and years ahead.
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Dr. Bradley J. Needleman, MD, is an Assistant Professor and Director of the Bariatric Surgery Program at The Ohio State University Medical Center in Columbus, Ohio. Dr. Needleman earned his medical degree from Mount Sinai School of Medicine; he has had specialty training in bariatric surgery at Mount Sinai and Ohio State University.
