Dr. Marc Bessler is assistant professor of surgery at Columbia University College of Physicians and Surgeons, and director of the Columbia University Center for Metabolic and Weight Loss Surgery. He is also the director of the Minimal Access Surgery Center at New York-Presbyterian Hospital/Columbia University Medical Center. A fellow of the American College of Surgeons, Dr. Bessler's clinical specialties include surgical management of morbid obesity, gastroesophageal reflux disease, laparoscopic surgery of the stomach, esophagus and hernia surgery, and natural orifice surgery. His research interests focus on hormonal, oncologic, and immune responses in laparoscopy.
He earned his medical degree from New York University School of Medicine, and completed his residency in general surgery and his fellowship in surgical endoscopy at the Columbia University College of Physicians and Surgeons and the Presbyterian Hospital in New York City.
Question: What are the biggest misperceptions about weight management surgery?
Marc Bessler: First of all I think the biggest misconception about overweight and obesity is that it’s the patient’s fault. This is truly a disease, now you’re right like we said before, you could eat less but that’s like telling somebody who has diabetes to control their sugar by just not taking in sugar and of course we tell 'em to do it but it’s very hard to do. Your body is mismanaging these things and so obesity is a disease, it is not the individual’s fault, it takes super human will power to keep obesity under control for the long term and that’s why these surgeries make sense. That these are very dangerous operations, I think 20 years ago the mortality rate of these operations were in excess of two percent. So of every hundred people that came in the operating room, two didn’t leave the hospital anyway, that’s not the case anymore. In a center of excellence, in a place that does this really well and a lot of it, the mortality rate for gastric bypass is about three in a thousan and the mortality rate for a lap band is less than one in a thousand. So these operations are much safer than they used to be. So much so that the risk associated with having the operation is way less than the risk of death from that operation over the ensuing years. Sorry, so much so that risk of having the operation is way less than the risk of having obesity for the ensuing years and you gain back not only the dollars put into it but the risk put into it over five years or so. Yet the other common misconception is that they always fail and people regain their weight back, some of the older operations didn’t work that well and some percentage of patients do gain weight back still but most don’t. With gastric bypass, I’d say 85 percent of patients maintain long term significant weight loss and with the lap band it’s probably close to the same just not as dramatic a weight loss.
Topic: Top experts working weight management surgery
Marc Bessler: Well that’s tough, I think that I hate to be specific about any institution, I think there’s centers of excellence, there’s two organizations that are documenting centers of excellence in weight loss surgery, that’s the American College of Surgeons and something called the surgical review corporation. A center that is documented as a center of excellence by those at least has more than the basics that they need to do this. A center that has one of these designations probably has long term follow up, so that’s really important and the surgeon’s probably have at least a minimum amount of experience doing this so that’s important. But truly you want somebody who’s done 500 or a thousand of these operations, the learning curve goes on probably to about 250 operations and then some. You want somebody who’s offering you all types of operations, not somebody who’s selling just one type or somebody who does 99 precent one type of operation because they’re probably trying to fit you into their operation, not find the best operation for you and you want some place that has a program for long term care and management and if you have all those three components you’re probably in a place that’s safe.
Question: What should the public know about weight management surgery?
Marc Bessler: Well I think that the most important thing to know is that right now less than two percent of people who qualify for surgery are having it. In most places that’s because patients really aren’t choosing it, I think there’s misconceptions about the risk and the benefits of this operation. These operations save lives, they make people have better quality of life, they make people healthier, they make people live longer. But there is some up front risk and you need to be at a center of excellence as we talked about, a place that does these really well to minimize that risk and overall the benefit is definitely there for almost everyone who qualifies for this operation and is appropriately evaluated. So I think that’s really, really important. The other important thing to know is that a lot of states, not New York fortunately but a lot of states the insurance companies don’t really allow patients to have these operations. The patients either have to fight, they get denied, they’re excluded from this and I think that’s really important. I think public health policy needs to be such that when things are medically necessary, when things are medically valuable, they aren’t denied patients and this is one area I think obesity in general is one area of sort of allowable discrimination because the public perception is still that obesity is the patient’s fault and if it’s the patient’s fault, we don’t have to pay money to give them an operation that isn’t gonna work anyway in their minds and that’s sort of the concept here. You wouldn’t hold back open heart surgery from somebody who has heart disease because they don’t eat a low fat diet and smoke. You have the operation and you educate them about proper diet and smoking, same thing here. You wouldn’t hold back a lung cancer operation from someone who has a history of smoking and we don’t hold back liver transplants from someone with a history of drinking, why, we recognize these as diseases with mortality associated with them and obesity is the same. Even more so, you don’t need to smoke to live, you don’t need to drink to live, but you need to eat to live. So you can go cold turkey off those other things, you can’t go cold turkey off food and really then it becomes a problem of regulation of amount, which is much harder than just stopping, you can’t stop eating therefore the disease is about regulation of the amount that you eat and that’s much, much harder to do.
Question: Insurance companies often do not cover weight management surgery: how can people afford it?
Marc Bessler: Well so how can people finance surgery, it’s two things, number one you can find an insurance company that does cover it, sometimes that’s a possibility, certain states almost everybody covers it. In New York it’s almost mandated, you’re right that obesity does disproportionately a bit effect the lower socioeconomic status, it’s unclear exactly why, perhaps fast food, things like that is more prevalent. There’s financing available through some institutions for this, so you can, you know, put it on a payment plan if you will. But again lower socioeconomic status folks, people who, you know, are relatively poor might not be able to afford a 20,000 or a $15,000 operation even paid off over time. I tell people who can somehow squeeze it together, you’ll put a car on financing even though you otherwise might be able to take mass transit because you want a car, 15 to $20,000 operation is affordable on financing if you recognize this is for your quality and length of life. Maybe more important than having a car in some ways. So I’m not telling people they should run out and pay for these operations if there’s other alternatives, certainly getting insurance to cover it, Medicare covers this at centers of excellence, Medicaid in New York covers it but not in all states and I think working to get legislation in those areas, working to make sure in the states that this isn’t routinely covered, to make sure that it is routinely covered is an important effort.
Recorded on: 6/16/08