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Recently reported research suggests that for some patient groups, the risks and costs of bariatric surgery may be greater than previously determined.
Several studies of gastric bypass surgery on patients 30–50 years of age have found near-term postsurgical death rates of 0.1–2%.1,2
But an analysis of Medicare beneficiaries showed that the outcomes vary much more, depending on the patient population and the track record of the medical center, according to a report by David R. Flum, MD, of the University of Washington, and colleagues published in October in JAMA.3
The investigators determined the risk of early postsurgical mortality among 16,155 Medicare patients treated during 1997–2002. The group found a 30-day mortality rate of 2%, which rose to 2.8% at the 90-day mark and 4.6% at the end of 1 year.
In general, the risk of death was greater in men, and the 1-year death rate
was greater among patients 
65 years old (11.1%) than in younger patients
(3.9%). According to the researchers, older Medicare patients are five times
more likely than younger patients to die within the first year.
A second JAMA paper examining the rate of hospitalization before and after Roux-en-Y gastric bypass surgery on 60,077 patients in California found that nearly 20% were hospitalized within the year following the surgery—nearly double the rate hospitalized in the year preceding the surgery.4
"We aren't saying that bariatric surgery is a bad thing, because we haven't addressed all the benefits, but rather this is what you should expect if you have the procedure," says lead author David S. Zingmond, MD, PhD, of the University of California Los Angeles Center for Surgical Outcomes and Quality.
Bariatric surgery is "a new technology," Zingmond says. "A lot of people are using it without a sense of the personal costs. People need to be realistic."
The number of bariatric procedures performed in the U.S. has grown rapidly in recent years, according to the American Society for Bariatric Surgery (ASBS): About 150,000 bariatric procedures were projected for 2005, 10 times the number in 1997.
ASBS President Neil Hutcher, MD, contends that the recent JAMA papers don't reflect the general practice of bariatric surgery across the nation. Flum's group examined "a very highly select, uncontrolled group of patients" that is disabled by obesity and likely to suffer comorbidities, according to Hutcher.
"It's not easy to be considered disabled by the government," he says. "You have to be pretty damned sick."
Like all surgical procedures, success rates are likely highest and complication rates lowest at centers with surgical teams that have done enough cases to develop proficiency in bariatric procedures, Hutcher says.
Flum says the problem isn't that too many procedures are being done, or
that patients are poorly selected, but that there are too many subpar surgical
teams in practice. "The `poor performers' do skew the mean, but not in
the way you might think," he says. "In our study, older folks did
just as well as younger patients when operated on by the most experienced
surgeons. These `worst performers' skew the mean because there are more of
them, not because of a statistical oddity." 
References
2. Buchwald H, Avidor Y, Braunwald E, et al.: Bariatric surgery: A
systematic review and meta-analysis. JAMA 292: 1724–1737, 2004.
3. Flum DR, Salem L, Elrod JA, et al.: Early mortality among Medicare
beneficiaries undergoing bariatric surgical procedures.
JAMA 294:1903–1908, 2005.
4. Zingmond DS, McGory ML, Ko CY: Hospitalization before and after
gastric bypass surgery. JAMA 294: 1918–1924, 2005.
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