By Stephen Spotswood
CHARLESTON, SC — With bariatric surgery becoming more common and reliable, VA medical centers are employing the treatment more often in patients previously unable to lose weight and reverse co-morbidities associated with obesity.
Questions remain, however, about the surgery’s long-term effects.
According to the Centers for Disease Control and Prevention, approximately one-third of U.S. adults qualify as obese, with a body mass index (BMI) over 35. In the VA patient population, the rate is 32%.
Obese patients are at greater risk for heart disease and diabetes, as well as some forms of cancer. Overall, obese individuals spend 42% more on medical expenses, 77% more on medications and, for those with the most severe weight problems, can expect to live a decade less than non-obese individuals.
The bariatric surgery program for Veterans’ Integrated Service Network (VISN) 7 at the Charleston, SC, VA Medical Center is trying to prevent those complications in obese patients who can’t lose weight by other methods.
Rana Pullatt, MD, director, VISN 7 Bariatric Surgery Program
Three years ago, Rana Pullatt, MD, sought to start a new bariatric surgery program at the Charleston VAMC, modeling it after a similar program he had begun at the Medical University of South Carolina, which is attached to the VA facility. After two years of getting funding and training staff, the program became operational.
“In the last year, we have performed 18 bariatric surgeries at the VA hospital, most of them laparoscopically. One of which was open surgery, because the patient had preexisting scar tissue from earlier surgeries,” Pullatt said. “A little over half of them were laparoscopic gastric bypass, and the rest were laparoscopic sleeve gastrectomies.”
Pullatt describes the results as extremely successful. “We have had no mortality or leaks from the procedure, and 95% of these patients have achieved tremendous weight loss.”
The majority of the patients also have been taken off insulin and other diabetes medications, sometimes very soon after surgery.
“What we’ve realized over the years of doing this is that weight loss happens over a long course of time, but diabetes resolution happens within weeks,” Pullatt said. “Research has shown that rerouting the intestine, especially the upper gastrointestinal tract, actually [ameliorates] type 2 diabetes.”
Admittedly, VA’s program has been extremely cautious in accepting patients for surgery. The maximum BMI of a patient that Pullatt has treated outside VA is 75, but in VA the maximum is limited to around 55, which reduces the chance of surgical complications.
“The first year, we wanted to play it safe,” Pullatt said. “We’ve been very selective.”
Despite the large number of patients who could benefit, Pullatt said he sometimes has difficulty convincing them that the procedure is safe.Bariatric Surgery Increasing at VA, Questions Continue on Long Term Benefits
“In the early years of bariatric surgery — before the staple technology got very good — it wasn’t as good,” he said. “People were doing them openly and not laparoscopically. I think, over time, the skill level of surgeons doing them laparoscopically has also gotten so much better.”
The mortality rate for laparoscopic gastric bypass is 0.1%, Pullatt noted. That is compared with a 0.9% mortality rate for hip replacement, he said.
Pullatt said he has had patients with comorbities seek out the program.
“My oldest patient, 68, had colon cancer,” he recounted. “We did a laparoscopic resection. His BMI was 58, and his colon was covered in fat. I told him, ’Once we get you through this, we need to talk about weight loss,’” Pullatt said. “As soon as we started the bariatric program, he walked back into my clinic on his own. We did a laparoscopic gastrectomy, and he’s lost weight tremendously.”
“This is life altering, life-saving surgery,” he added.
Looking At the Long Term
The longer-term outcomes of bariatric surgery, both in terms of mortality rates and cost are still under question, however. VA research over the last year has indicated that, at least for the older, male VA population, bariatric surgery may not have as much impact on death rates and healthcare costs as previously thought.
Matthew Maciejewski, PhD, a researcher with VA Health Services Research & Development at the Durham, NC, VAMC, has looked at the full surgical experience of veterans who have undergone bariatric surgery.
“Since VA was spending a good bit of money to provide the surgery for those eligible for it, it seemed worthwhile to determine if the veterans’ experiences were good,” Maciejewski said. “We also really wanted to inform the evidence base. All prior studies were on predominantly younger women. There hadn’t been a rigorous assessment of survival and expenditures on older men.”
In two papers — the latest released early this summer — Maciejewski and colleagues compared surgical patients with those who had not received surgery. They found similar mortality rates and similar expenditures three years post-surgery. This was counter to prior findings looking at the predominantly younger, female surgical population.
“Our understanding of it is that the veterans we examined were older and had a higher burden of comorbid conditions,” Maciejewski said. “With the potential benefits from bariatric surgery, given the duration of the conditions they had and the severity and number of them, there was not as much room for improvement in the outcomes.”
He stressed, however, that there are benefits from bariatric surgery for this group that go above and beyond the long-term effects.
“There’s no doubt there is a positive experience for this group,” he said. “There’s tremendous weight loss. And, in work published several years ago, many of these veterans were able to discontinue lipid and diabetes medication.”
Future research will bring more nuanced understanding to the surgical outcomes. The previous studies only looked at veterans who had surgery between 2000 and 2006. The number of veterans having the surgery has only risen since then.
“With that larger statistical power and sample size, we’ll be able to look at subgroups to see who’s really benefiting from the surgery,” Maciejewski said. “We’ll also be able to track outcomes longer.”
Researchers also will look at additional outcomes, including comparing weight changes as well as looking at changes to blood pressure, diabetes indicators and cholesterol levels. The goal is to understand exactly what can lead to medication discontinuation.
Future studies also will follow earlier surgery patients for longer. “It could be that survival and expenditure outcomes can be observed farther out,” Maciejewski noted.
First results from the next study should be available in 2013.
Back to September Articles
When Terrence O’Neil, MD, retired as chief of nephrology at the James H. Quillen VAMC in Johnson City in December 2016, he left in his wake decades of work treating kidney disease—nearly 35 years in the Air Force and DoD, plus 11 more at VA.
A long sought-after bill that would make it easier for Blue Water Navy veterans to receive Agent Orange benefits has been passed by a key House of Representatives committee.