While gastric bypass surgery may help obese people improve their health by shedding weight, the procedure may have a darker flipside when it comes to patients' risk of death from suicide and a continued risk of heart disease.
According to a study published in the current issue of the journal Archives of Surgery, this increased risk may indicate that bariatric surgery patients may require more intense follow-up in the months and years after their procedures.
And while heart disease proved to be a major killer, most striking was the increase in suicide and accidental drug overdose after such surgeries, said Dr. Cori McBride, director of bariatric surgery at the University of Nebraska Medical Center in Omaha, who was not affiliated with the study.
"Bariatric surgery does not cure depression, and these patients need treatment for depression," she said.
Dr. Daniel Jones, director of the bariatric program at Beth Israel Deaconess Medical Center in Boston, agreed that the most startling finding is the risk of suicide after gastric bypass.
"This emphasizes the very important role of long-term follow-up, support groups and access to psychological services — which are not always covered by insurance companies," he said.
"Bariatric surgeons at accredited bariatric centers have committed to preoperative screening by multidisciplinary teams, and to long-term follow-up," he said. "Insurance carriers need to make the same commitment to health maintenance."
Weight of the Evidence
In this study, researchers examined records of 16,683 bariatric surgeries among Pennsylvania residents. They found a substantial number of excess deaths attributed to both suicide and heart disease after surgery.
The death rates appear higher in men than in women, and increase with age, especially among those over 65 years of age. As postsurgery time increased, so did the death rates, with heart disease topping the list.
"This study underscores that coronary heart disease is the leading cause of death in these extremely obese patients," said Dr. Anita Courcoulas, chief of minimally invasive bariatric and general surgery at the University of Pittsburgh Medical Center.
And, according to Dr. Alexander Abkin, a laparoscopic bariatric surgeon in Florham Park, N.J., many of these deaths may be preventable through more diligent monitoring after surgery.
"The lack of good follow-up does potentially increase the patient's risk long term," he said.
But despite the risks, McBride said she is not necessarily convinced that bariatric surgery leads to excess deaths in the big picture. She cited the McGill study from Canada, a 2004 project that evaluated the health gains of those who opted for weight-loss surgery. This study demonstrated that, for morbidly obese individuals, the benefits of these surgeries outweighed the risks of not having them performed.
Since Canada has a national database of all citizens, the McGill study takes into account who is obese and who is not. Contrarily, the current study compares the death risk of obese patients to that of the general population, some of whom are not obese.
While McBride believes that the lead researchers did the best they could based upon the limited database of gastric bypass operations in the United States, she believes that results from the McGill study are more relevant when counseling obese patients as to whether they should undergo bariatric surgery.
Other researchers agreed that, for patients who need it, gastric bypass surgery is beneficial.
"Most recently, studies this year in the New England Journal of Medicine also proved survival advantage to weight-loss surgery," Jones said.
Surgery Can't Cure All Ills
Still, those who are morbidly obese shouldn't look to gastric bypass as a cure-all.
As McBride pointed out, previous studies show that bariatric surgery lowers the mortality rate. "We do not know if it will reverse years of being obese.
"Surgery can lower their weight and impact their health positively from here on out but can't reverse years of damage," she said. "We don't have evidence that surgery reverses years of damage."
And doctors agreed that no matter how effective an operation like gastric bypass may be, what happens after the patient leaves the operating room is equally important.