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Boston Magazine: October, 2005

PROBLEMS WITH WEIGHT-LOSS SURGERY:The Incredible, Perilous, Money-Making, People- Shrinking Machine

by Jake Halpern

AT FIRST GLANCE, the scene looks like a 30th high school reunion--balding men in golf shirts mixing with middle-aged women in eveningwear sipping drinks and chatting amiably in a garish banquet room in Braintree--but then someone turns on a microphone. "My name is Jody," announces a short woman with spiky black hair and heavy eyeliner, "and I have lost 250 pounds." There is polite applause and Jody passes the microphone to Linda, who declares that she has lost 165 pounds. Next comes Dave, who announces that he has lost 280 pounds, which is roughly equal to the weight of two tractor-trailer tires.

Gradually the microphone makes it around the room, as all the guests take turns announcing their names and the amount of weight they've shed. When this is done, the master of ceremonies--a woman in her 30s named Marie Desjardin who has lost 142 pounds--explains that there will be a contest in which everyone has to guess the total number of pounds that have been lost. An excited murmur ripples through the crowd. After all the guesses are submitted, Marie clears her throat and announces into the microphone: "We have lost a grand total of 9,201 pounds." More than four and a half tons.

"Holy shit!" gasps an elderly woman at the far end of the room.

"Yes," replies Marie. "And the winner is . . . "--there is a dramatic pause--". . . Evan, who guessed 8,437 pounds."

The crowd breaks into a boisterous round of applause.

As it turns out, these 9,201 pounds were lost not through Atkins or South Beach, or even good old-fashioned exercise, but through surgery, which virtually everyone in the room has undergone. Boston has become an international capital of weight-loss surgery, bringing in a steady flow of cash to many of the area's financially ailing hospitals. Although surgeons have been stapling stomachs since the 1960s, the procedure has become exponentially more popular within the past few years, and many patients who've been through it are finding their way to support groups like this one.

Tonight's event is sponsored by the Friends of Weight-Loss Surgery, or FWLS, a Boston-based group that gathers once or twice a year for a retreat. Typically, FWLS retreats include a big Saturday night gala. Before the hard partying begins, however, there is usually a speaker who talks about the psychological challenges of the surgery or the medical complications it can cause. Tonight's speaker is Kymber Estes.

Kymber's story is, from start to finish, a worst-case scenario, and as she begins to tell it, the giddy excitement in the banquet room recedes into silence. "After my surgery, I was in a coma for 17 days," Kymber says almost casually. "I had major complications including sepsis, peritonitis, pneumonia, two blood clots in my neck, and an open incision for a year because it was infected and they couldn't seal it up." As if all this weren't bad enough, the staples in Kymber's stomach had given way and she was now scheduled for a nine-hour "re-do" operation that her doctors told her would be very dangerous. "When I go in for surgery on Wednesday, the doctor is trying to save my life," Kymber says. "I've done my living will and, if you don't have one, you all need to do it." Kymber pauses to regain her composure. "Anyway . . . ," she stammers, "this is the time for us to be the divas that we are--no matter who laughed at us or made fun of us in the past."

If Kymber's experience were a freak occurrence, her story might be easily dismissed. It's not. A University of Washington study, the first to look at gastric-bypass survival beyond hospitalization, reports that 1.9 percent of patients die within 30 days of the procedure. As many as 20 percent experience complications, and some of them require second operations, which are typically much more risky. Nonetheless, for many prospective patients, the desire to be thin is so dire that it trumps any concerns about the dangers.

Midway through the FWLS dinner, I get to talking with 21-year-old Sarah Roberge from Manchester, New Hampshire, one of the very few "pre-ops" in attendance. In the world of weight-loss surgery, the pre-ops are the newbies, the people who haven't had their operations yet. Sarah weighs 342 pounds. "I hope to lose about 170 pounds, and that would put me at a normal weight for someone my age and height. Anything would be better than now," Sarah says.

"Being just 21 years old, it is hard to think that guys--it's hard to say this--guys don't look at me," Sarah says, swallowing hard. "And I feel like I am missing out on that companionship. I have also had to put other dreams on hold. I wanted to be an ichthyologist and study fish, but because of my size I could never scuba-dive."

When I ask Sarah how long she has been struggling with losing weight, she replies that it has been an issue since the second grade. "It was tough as a kid," says Sarah. "I remember being picked on horribly--like, I had a red winter jacket and the kids used to call me 'Mrs. Claus.' So I tried to watch the calories, I tried Slim-Fast, I tried Sweatin' to the Oldies, but it didn't happen. And if you are overweight it's harder to exercise. I get hot much more easily. I have terrible joint problems in my ankles, knees, and hips. Even walking half a block to work would give me terrible muscle pains in my thighs."

Sarah stares longingly out toward the center of the room, where some of the post-ops have begun to dance to a Van Morrison song. "Could you ever see yourself out there?" I ask her finally.

"I'm not very coordinated," Sarah says softly, almost inaudibly. "But I could see myself giving it a try."

"Are you worried about the surgery?"

"Kymber's speech scares me," she replies with a slight nod. "It makes me realize that I want to tell everybody who means something to me that they do, because I might not get a chance to later on." Sarah pauses and then concedes--rather uneasily--that this surgery could end very badly. "But that doesn't scare me to the point where I don't want to do it," she adds quickly. "This surgery is kind of the last chance for me to have a life."

__________

Not long after my evening in Braintree, I pay a visit to Dr. Edward Mun, a bariatric surgeon at Faulkner Hospital and an assistant professor at Harvard Medical School who has performed weight-loss surgery on hundreds of patients, including one of the people I had met at the FWLS dinner. According to Dr. Mun, weight-loss surgery is quickly gaining popularity, not just with patients but with surgeons. "If you are going to be a surgeon, you want to make sure you have enough cases, which is how surgeons make money," he says matter-of-factly. "Many surgeons who are in stiff competition for colon or hernia operations may find that this is a field with an unlimited number of patients." Why unlimited? Because, as Dr. Mun is quick to point out, with America in the midst of an obesity epidemic, there is a seemingly inexhaustible supply of grossly overweight people.

Dr. Mun leads me down the hallway to the surgical ward, where we meet one of these patients: a plainly obese, middle-aged woman named Tina, who is sitting by herself in a formless blue gown, waiting for her operation. When I ask how she feels about her imminent procedure, she forces a meager smile and responds that she is looking forward to a new life, one in which she can walk around, play with her kids, and get into her clothing without a major ordeal. "I don't expect miracles," Tina adds softly. "I am not going to be Cindy Crawford."

Half an hour later, I get into scrubs and join Dr. Mun in the operating room as he cuts into Tina's flesh and inserts a device called a harmonic scalpel into her body cavity. Standing nearby is a wide-eyed medical student, who has thrust a small surgical camera into another incision in Tina's belly. This camera is connected to two television monitors that are now displaying Tina's intestines, which, when viewed closely, resemble a slopping pile of uncooked chicken tenders. Using the harmonic scalpel, Dr. Mun presses into the thick of this and starts cutting away. A nurse appears to yawn. Someone else flicks on a boom box, which is soon playing Ray Charles's Georgia on My Mind. It's another day in weight-loss-surgery land.

If the atmosphere in the operating room seems humdrum, it might be because Dr. Mun typically does three to four weight-loss surgeries a day. And he isn't the only Boston doctor staying so busy. The number of weight-loss surgeries has increased nearly 500 percent in the past five years, according to the American Society for Bariatric Surgery. In Massachusetts the number has jumped from 630 such surgeries in 1999 to 3,036 last year. This means there are now about 60 people undergoing this surgery every week in this state.

Bariatric surgery has a long history in Boston. Dr. George Blackburn, who began his career as a bariatric surgeon at Deaconess Hospital more than 30 years ago, is considered one of the grandfathers of the field. The reason you may not know this--the reason many people don't know this--is that the field itself has not been particularly well respected within medical circles. "Unfortunately people have the impression of weight-loss surgery being merely cosmetic," says Dr. Malcolm Robinson, who runs Brigham and Women's Hospital's Program for Weight Management. "Then you have celebrities like Al Roker who've had the surgery and are embarrassed about it. I had a patient just yesterday who has still not told her family anything about the surgery--she didn't even want me to call them--because she is ashamed. Society still has a significant bias against obese people. Even 10 years ago people would make very derogatory remarks, not just about the patients, but about the surgeons." But times are changing. Nowadays, says Dr. Robinson, the stigma is waning and his is quickly becoming "one of the hottest fields in surgery."

One reason the industry is taking off is that insurance companies are starting to pay for the surgeries. Blue Cross Blue Shield of Massachusetts will typically shell out $12,000 to $18,000 to a hospital to cover the cost of one gastric-bypass surgery. Exactly how much of this is profit depends on how efficient the doctors are. If they use a minimum of staples and nail the procedure on the first try, it can be extremely lucrative.

For insurers, the business advantages are clear. The average annual cost of treating an obese person in 2002 was $1,244 more than the cost of treating a person of healthy weight. This means that within the span of 10 or 15 years an insurer would theoretically make back its "investment" and possibly then some.

All of this is good news for struggling hospitals. To begin with, the procedures themselves are elective, which allows the hospitals to wait and verify a patient's insurance coverage, cash a personal check, or line up some other means of financing. On top of this, many patients also require plastic surgery to remove their excess skin, and this, too, can be quite profitable for hospitals. "Bariatric surgery is the current gold rush in medicine," says Roland Sturm, a senior economist at the RAND Corporation, who has been studying obesity in America. "And no hospital or doctor wants to be left behind."

Weight-loss surgery has actually saved at least one hospital from financial ruin. Durham Regional Hospital in North Carolina, which lost more than $26 million between 1999 and 2002, reportedly turned itself around by building up a highly profitable weight-loss surgery program that helped generate a net operating income of more than $8 million last year. In the healthcare business, this kind of rags-to-riches story doesn't go unnoticed. At Boston's Brigham and Women's, the Durham Regional turnaround raised eyebrows. Dr. Robinson was among those who took notice. "I hate to turn a critical health issue into a business plan," he says, "but there is a chance for this to be a moneymaker if the doctors are providing quality care."

It would be an especially attractive proposition for many community hospitals that are financially on the ropes. Dr. Scott Shikora, who runs the New England Medical Center's surgical weight-loss program, says he has been approached by other hospitals that are looking to get in on the boom. "I often hear hospital administrators talk about services as product lines, and bariatrics, where there is a large potential for patients, is a very hot product line right now," Shikora says.

One problem is that some of these community hospitals are ill equipped to run safe weight-loss surgery programs. Last year, for example, a 38-year-old woman named Dawnmarie Fernandes died just 11 days after undergoing gastric-bypass surgery at Saint Anne's Hospital in Fall River. According to relatives, Fernandes's primary-care physician warned her that her failing health made her a poor candidate for the surgery. She underwent the procedure anyway at Saint Anne's, and soon after met her death. Stories like this one prompted the Massachusetts Board of Registration in Medicine to conduct a study, which found, among other things, that there had been 16 weight-loss-surgery-related deaths in the state between March 2003 and October 2004.

In light of all this, Roland Sturm's "gold rush" analogy seems quite accurate, but perhaps the community hospitals aren't entirely to blame. We live in a country that loves quick fixes--whether it's get-rich-quick pyramid schemes, get-happy-quick pharmaceuticals, or lose-weight-quick surgeries. What's more, we're obsessed with being thin. This, I suspect, creates a certain amount of desperation. For me, this notion really hits home during a conversation I have with Dr. Mun's patient, Tina. "My husband wanted me to lose weight normally," Tina tells me just before she's wheeled off for her surgery. "But it wasn't happening and now he thinks this is okay because he cannot stand to look at me."

__________

Even if Tina's surgery is a success and she becomes thinner than she ever dreamed, it might not solve her marital problems. In fact it might exacerbate them. Divorce rates are very high among patients who have had significant weight loss. I hear this not just from medical experts but from many of the "post-ops" I meet at the FWLS dinner in Braintree. As one woman puts it: "There are several of us who have lost weight--which gets your self-esteem up--and the husbands don't like it because suddenly you are not willing to sit back and be a nobody anymore."

Post-ops are prone to feeling angry at colleagues or family members who treated them poorly when they were obese. Dr. Robinson, at Brigham and Women's, describes many of his patients' mindsets this way: "Their feeling is, 'At 300 pounds people treated me like dirt, and now that I am 150 pounds, instead of treating me like dirt, you are treating me like a person--which you should have done all along!'" This, among other reasons, is why groups like Friends of Weight-Loss Surgery have begun to sprout up in Boston and elsewhere. In many ways, the real benefit of these gatherings--beyond the emotional support they offer--is the chance to step gingerly into the world of thin people and enjoy the newfound pleasures of dressing up, dancing, flirting, and generally having a good time.

During the FWLS dinner, I see this for myself when the dance party gets under way. After a dessert of fruit is served, the DJ flicks on his equipment and the room's speakers rumble to life with the song "Celebration," whose lyrics exhort everyone to "Celebrate good times, come on!" There's a sudden rustling of dresses, and moments later the dance floor is packed with undulating female bodies. The only lingering traces of obesity are the flaps of excess skin hanging from some of the women's arms. "We call those 'wings,'" explains Marie Desjardin. "I like to say that I could go to Timbuktu and back with mine. But that is what is so great about tonight. You will see people take off their jackets, and six inches of skin hangs off. And I would never do that in public.

"We are generally people who did not go to our proms," Marie continues. "I was 300 pounds in high school and I was too large to be asked to my prom. So this is our chance to dress up to the nines, dance, dine, and party."

For some of the evening's revelers, dressing up goes beyond just getting a new set of clothes. "I recently got contact lenses, had my top teeth whitened, and had surgery to remove the excess skin from my abdomen," says Jerry Cohen, who lost 185 pounds and is one of the few men at the dinner. "I'd considered hair transplants, but decided against it."

According to Jerry, this event is downright tame compared with some of the others he has attended. When I press him for details, he describes a rowdy three-day bacchanalia, which included drunken revelry, lingerie shopping, adultery, and a night out at a strip club. "You have all of these people who have been kind of repressed and isolated their whole lives, and suddenly they have these new bodies and they want to try a lot of things they missed out on," he explains. "They just let it out in one weekend."

At the Braintree dinner, though it never gets truly out of hand, even I can sense the raw pulse of renewed life surging through the place as the women dance into the night--smiling, swaying, whooping, hollering, pounding the floor with their shoes, and embracing each other as their mascara runs with tears and sweat.

Perhaps no one is more struck by this than Sarah Roberge, the 21-year-old pre-op. "To me that night was incredible," Sarah later recalls for me. "I was astounded to see how lively these people were. They were living to the fullest."

Sarah finally had the surgery herself. By her one-month post-op appointment she had lost 16 pounds. She has since lost 74 more. She says she already feels more hopeful. One source of her hope is her mother, who had weight-loss surgery herself a few years ago. "Mom says that people treat her differently now," says Sarah. "They don't look at her with pity or disdain. I look forward to that."