A Sad Tale of Two Bypass Surgeries

Let’s talk about two different kinds of bypass surgeries. Both of them are the subject of studies presented at the American Heart Association’s scientific meeting this past weekend. But that’s where the similarities end.

Operation C

We’ll call the first of these procedures Operation C. More than 200,000 people have these surgeries done every year. It costs about $45,000 each time. Between one and three percent of patients die before they leave the hospital. Typically, they’ll spend a week in the hospital. Recovery usually takes between six weeks and three months.

The study presented at the AHA meeting found no advantage in primary outcomes for patients who had Operation C compared to patients who got medical care alone. The chair of this landmark study, Judith Hochman, said “there was no suggestion that any subgroup benefited.”

Operation G

The other kind of bypass on the agenda is a bit simpler. Most patients stay in the hospital for only two or three days. Recovery typically takes three to five weeks. It costs an average of $23,000. Deaths occur in less than 0.5 percent of patients in the first 30 days after the operation.

Operation G extends life. It reduces the risk of heart attacks, diabetes, and certain cancers. It often improves quality of life rather dramatically. In addition, the new data presented this weekend demonstrates a lower risk of stroke for people who have this procedure. But only a fraction of those who could benefit – about 41,000 – have this procedure each year.

Odd Choices

In case you haven’t guessed, Operation C is heart bypass. More specifically, it is a coronary artery bypass graft (CABG). Another option that was part of the huge study presented at the AHA meeting is the placement of a stent to open up a blocked coronary artery. It’s still invasive, but less invasive than a CABG. It’s costly – about $25,000 – even though it’s not as expensive as a CABG.

Here’s the kicker, though. Whether people got a stent or a CABG, they didn’t live any longer than patients in the medical care arm of this study. They didn’t cut their risk of a heart attack, hospitalization, or an event that required CPR.

The only positive for the group that received the invasive procedures was fewer heart pains and better quality of life. But that was only for people with troublesome heart pains at the start of the study. Note that this was a randomized, controlled study. So the results are quite compelling.

Of course, Operation G is gastric bypass. More rewards. Less risk. Longer life. Yet some doctors are slow to recommend it and many patients refuse to consider it. Professor Caroline Apovian sums it up for us:

I think that the stigma of obesity rings clear here. Patients go in for procedures on their heart that are useless before they would have a procedure that would put their obesity into remission and help them live longer.

A Sad Tale

The tale of these two bypass surgeries is sad indeed. Blame and shame get in the way of preventive care for obesity that could reduce the need for heart procedures down the road. Fear and a dysfunctional healthcare system lead people to wait until they feel their life is on the line. Then they have a costly and risky heart procedure that offers little or no benefit.

This is no way to run a health system.

Click here for more on the ISCHEMIA trial of cardiac procedures and here for more on the study of bariatric surgery. For the study abstracts, click here and here.

Stent, photograph © A.M.D. / flickr

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November 18, 2019

3 Responses to “A Sad Tale of Two Bypass Surgeries”

  1. November 18, 2019 at 8:46 am, John DiTraglia said:

    wow. that’s excellent. I’m going to write a letter to the editor of our local paper plagiarizing this – but citing it. thanks.

  2. November 18, 2019 at 1:48 pm, Angela Golden said:

    This is incredible. Looking forward to this publication to add to my bias and stigma lecture! As always thanks Ted

  3. November 22, 2019 at 4:04 pm, John Dixon said:

    Sad indeed. Bias and discrimination clear winners vs evidence based medicine.

    The list of surgical procedures with little or no benefit for patients grows, while bariatric metabolic surgery suffers bias and discrimination.

    But our house needs to be in order. Adjustable gastric banding has an excellent evidence base with clear positive health outcomes. As an option it has been dismissed by many bariatric metabolic surgeons. Effective medications and very low calorie diets have a trivial community uptake despite being evidence based. Bias and stigma regarding obesity treatments are systematic, and clearly evident in those among us who are engaged in treating those living with obesity.

    We need to address our biases and prejudices by engaging evidence based care ourselves before others can be expected follow.

    We have a growing number of very effective tools let’s promote and support their appropriate use.