Look closely before leaping

For more than a year, medical and legal controversies surrounding an especially radical form of bariatric surgery have been in the Australian news. While the legal and medical investigations have yet to be resolved or all the facts made public, what is striking in following this story are two precautionary lessons that it highlights for patients and their families.

Even when prospective patients are certain they understand the risks of these surgeries, as this story reveals, patient educational information can mean something very different than it seems to be saying. Most consumers probably have a different understanding of surgical risks than surgeons, for instance. It pays to read and research carefully. It also reminds us that there are numerous different bariatric procedures, with every surgeon promoting his/her own version, without any long-term clinical research showing their safety, effectiveness or favorable risk-benefit ratios. Even the most experienced surgeon and intense follow-up cannot change the risks of the procedures themselves and it can be valuable to get second opinions before making a decision.

The surgeon who’d told 60 Minutes in response to questions about the possibility he might lose his license to practice medicine: “don’t be stupid...it won’t happen,” has surrendered his medical license. As the Australian reported this morning, he has been under investigation by the Medical Board of Queensland surrounding his performing an especially extensive bariatric procedure, the bilio-pancreatic diversion.

That 60 Minutes special, The Greatest Lost, which aired on October 11^th, had reported that six of Dr. Russell Broadbent, M.D.’s, patients died within the first year, and more are suffering severe complications after undergoing his particularly drastic form of surgery. Profiling various patients, including 57-year old Ursula MacLeod who died just 3 months after her surgery, reporter Liam Bartlett explained the surgical technique:

Dr Broadbent...literally cut out three-quarters of her stomach and a whole lot more. It's called bilio pancreatic diversion and this is how it works. The first step of the operation removes most of the stomach, leaving only a narrow tube to hold food. Then the surgeon cuts the small bowel to a fraction — about a 10th of its original size — and re-attaches it to the stomach. The short length of bowel means when the patient eats less fat is absorbed but there's also less nutrients going into the body. And that is the big problem. Patients can literally die from a whole host of complications caused by malnutrition.

Dr. Michael Talbot, a Sydney surgeon, told 60 Minutes that he and other surgeons at the Gold Coast hospital won’t do the BPD procedure because the complication rate is unacceptable high. “It's at least 10-20 times riskier than some of the more common procedures,” he said. Increasingly, he and his colleagues are undoing this operation, as best they can, to reverse it.

Bartlett reported that the Queensland Medical Board found, [quote] “serious deficiencies” in Dr. Broadbent’s practice. The doctor responded by saying that was “wrong and...will eventually be reversed simply on the ground that it is totally illogical.” He said he’s been a trailblazer and he would prove them all wrong. He denied that he caused the death Mrs. MacLeod, saying, “nothing went wrong with the operation, the operation went perfectly normal.”

The Gold Coast newspaper also reported last October that of the 110 patients who’d had this procedure by Dr. Broadbent at the two Gold Coast hospitals, six patients died — but all the deaths occurred after 30-days post-op... meaning they weren’t classified as surgical deaths. According to an Allamanda Private Hospital audit of his surgeries, of the six deaths, two patients had died of cardiac arrest, two died of septicaemia, one died of sepsis and one died from pulmonary embolus.

Dr Broadbent was reported by the newspaper as insisting the deaths were unrelated to the primary BPD surgery:

These were not operative deaths. The accepted standard of surgery is measured in 30-day mortality and my 30-day mortality rate is zero. That is better than the world standard.

He blamed the deaths on the failure of medical staff and on the patients, themselves. The Medical Board of Queensland had placed seven conditions on Dr. Broadbent on August 29, 2007. One restricted him to perform the BPD procedure only at hospitals with a nutritionist or dietitian on staff, which he told the paper was “a total waste of time.” He added:

Any amount of planning will not prevent the rogue patients from doing what they want to do... and two of these people who died were rogue patients who just would not follow instructions. In the first year after surgery all these people are at risk because they still have all their original co-morbidities (related conditions)... There's only one thing we guarantee with this operation — if they don't do what I ask them they'll end up in trouble. The rest is up to them...

It's lifesaving surgery, it's life-extending surgery that can save the community millions. Bear in mind these aren't well people — you see them waddling down the street.

The Gold Coast hospitals have been unable to get insurance to cover the procedure, unlike here in the U.S., and has disallowed it to be performed. According to the Gold Coast paper:

Dr Michael Coglin, the chief medical officer for the Allamanda Hospital's owner, Healthscope, said BPD surgery had not been performed at the hospital since the time his company took over management in April, 2005. He confirmed that hospital insurers had before that time notified the hospital they would not cover claims resulting from BPD, and Dr Broadbent had been told he could no longer perform the surgery there in March, 2004.

Dr. Broadbent’s website provides an extensive history of his 39 years of medical experience. He has performed bariatric surgeries for twenty years at two Gold Coast hospitals. He no longer does bandings, he says, preferring the BPD and tube gastrectomy with duodenal switch. He also offers tummy tucks and full body surgical contouring procedures for bariatric patients after they lose weight.

The patient information provided at his website says BPD “combines removal or exclusion of 2/3rds of the stomach along with a long intestinal bypass which significantly reduces the absorption of fat.” He also removes the appendix and gallbladder.

Among the advantages, he tells patients, is that it offers the best weight loss of any procedure, weight loss is well maintained and that it’s a “very good option for revision if other techniques have failed.” Among the disadvantages mentioned are vitamin malabsorption and deficiencies, removal of the gallbladder, increased stools of 2-4 per day, and flatulence. The operative risks of the procedure in his patient literature state: “risk of death is 1:200.”

On the FAQ page specifically for the duodenal switch and BPD, the risks are discussed in more detail. Obese patients are at high risk because of their weight and comorbidities, he tells prospective patients, but surgery is “made safer by training, experience and precautions of those doing it.” He adds:

Because all patients are different it is impossible to be precise about risks but in this type of surgery there is a 1% risk of death within the first year after surgery. By proper preparation of patients we are able to minimize risks of this type of surgery. By total compliance with the instructions given to them, patients can minimise their own risks- If you do not intend following instructions given exactly and to the letter -then don't bother to go any further... The risks of obesity surgery need to be considered against the longer term risks of not having the surgery and the worsening of co-morbidities.

What are the benefits of obesity surgery? The figures comparing obese subjects who have had bariatric operations compared to those who have not show a 66% reduction in overal1 [sic] mortality after 10 years. Apart from living longer, those who have successful surgery have a greater reduction in co-morbid diseases — such as an almost 100% cure for type II Diabetes, hyperlipidaemias (cholesterol) and Hypertension (blood pressure) and a concomitant increase in life style factors and enjoyment of life...

Prospective patients hear that the surgical risks are only 1 in 200 patients and not one of his patients has died during the post-op period. They read that 1 in 100 may risk dying in the first year. Until the 60 Minutes report, few probably knew that more than 1 in 20 patients have actually died within the first year, meaning the actual risks of dying are 5 to 10 times what many may have gone into the surgery believing them to be.

How many prospective patients are also realistic in their understanding of the risks for complications? Or, do they believe that they will be one of the lucky ones, as profiled in the testimonial success stories on the website, complete with before-and-after photos, and not look further? Concerning complications, he tells prospective patients:

For example -since 1986 Not one of my obesity patients have needed to be admitted to Intensive Care directly from the operating theatre after their initial operation. All of my obesity surgical patients have left our hospital alive after their initial obesity surgical operations.

This is not to say though that complications have not developed later that have required further surgery, subsequent admission to intensive care or eventually died of a complication or of a preexisting co-morbid cause. It is emphasised that morbidly obese subjects pose a very high risk before surgery and despite all preparation, precautions and skills complications can and do occur. If you are not prepared to accept the inherent risks nor prepared to do everything required of you to reduce those risks -then do not consider obesity surgery.

What are the most troublesome complications? Gastric leaks (from the stomach) can occur within the first month after surgery. It is almost always at the same point, being the very top end of the stomach resection. The cause it not known and despite utmost care and attention at operation the rate is 2-4% world wide. Many can be treated by simple drainage, but they all take a long time to dry up and heat [sic]

Dr. Broadbent goes on to provide risk charts he says can indicate a prospective patient’s personal risks: Risks increase with age, doubling by age 65 years and older; risks double if you have a BMI over 30 and increase by 400% if your BMI is over 50; risks of complications increase 25-50% for every ‘obesity-related’ health problem; and they increase 50% for every previous operation. Most of all, he says, risks increase 100% to 500% for failure to follow his instructions “to the letter.” It would appear that complications are pretty much assured for most patients. Those patient stories, however, don’t appear on the website.

Being an informed, careful healthcare consumer

When trying to make any major healthcare decision, the same consumer precautions apply. Seek information on all sides and separate marketing from health information. Some of the earmarks of unreliable health marketing, according to Quackwatch, is if it plays on fear and caters to hope; appeals to our vanity; exudes confidence in the benefits and successes of its results; and shifts the burden away from its efficacy by saying you’ve come to them too late, but they’ll do their best (“that way, if the treatment fails, you have only yourself to blame”). Most of all, beware of anecdotes and testimonials, as that’s a sales technique, not neutral medical information. Finally, “don’t let desperation cloud your judgment.”