Too Fat for Surgery
Ever since Phyllis Warr was about 10 years old, doctors told her she'd drop dead if she didn't lose weight. They told her she wouldn't be able to walk at 35. They told her weight-loss surgery was her only hope.
"I sat, I listened, I did what I was going to do," says Warr, now a 61-year-old retired teacher who lives -- and walks -- in the Chicago suburbs. She weighs 320 pounds. "I didn't believe them."
So when a doctor told her years ago that she couldn't have knee replacement surgery until she lost weight, she didn't believe him either. Instead, she learned about how obesity, diabetes and asthma -- all of which she has -- affect surgical outcomes and "prepared [herself] for battle" against another doctor.
"The weather changes, it hurts like hell; I stand for a few minutes, it hurts like hell; I walk, it hurts like hell," she told him. "Can you do anything for me?"
This time, the answer was yes. "I was almost disappointed that I didn't get to fight," recalls Warr, who had one knee replaced in 2010 and the other in 2014, both without complication.
[See: 10 Questions Doctors Wish Patients Would Ask.]
Warr is among the more than one-third of Americans who are obese -- a height-weight combination that makes surgeries more complicated for surgeons, more risky for patients and more costly for the health care system, according to Dr. Robert Cima, a colorectal surgeon and chair of surgical quality at the Mayo Clinic in Rochester, Minnesota. "Across all surgical specialties, obesity is associated with increased length of hospital stay, increased readmissions, decreased rate of dismissals to home and increased cost," he said to a group of journalists attending an obesity research fellowship program in February.
As a result, some surgeons like the one Warr first saw won't operate on patients with high body mass indexes for some elective procedures, such as hernia repairs and knee and hip replacements, until they lose weight.
"It's a big issue," says Dr. John Morton, chief of bariatric and minimally invasive surgery at the Stanford University School of Medicine. "We talk about racial disparities in care and gender disparities in care, but there's actually weight disparities in care because these patients aren't getting needed therapy because of their weight."
From hip replacements to plastic surgery to cancer care, no type of surgery -- save those performed on the eyes -- seems to be unaffected by obesity, Cima said.
Obese patients who undergo some spinal surgeries, for example, have longer procedure times (about 25 minutes longer on average), spend more time under anesthesia and in the hospital, and are more likely to be admitted to the intensive care unit and need a ventilator than patients who aren't obese, one study out of the Mayo Clinic last year found. They also cost the system over $500 more on average than the same procedures among nonobese patients when controlling for age, gender, procedure type and other factors. Another study showed that obesity makes hip surgery more complicated and longer, and raises the risk of future dislocation. Yet another found that, while still rare, obese patients were significantly more likely to die after colorectal cancer surgery than nonobese patients, and their hospital bills were $15,582 greater.
Obese patients who undergo heart surgery, meanwhile, have been shown to be more than two times more likely to develop a serious, potentially fatal infection of the breastbone. "When you talk to cardiac surgeons, the thing they fear the most is this," Cima said in an interview with U.S. News.
Even surgical treatments for thyroid cancer have been refused to some morbidly obese patients, since treatments like surgery and radioactive iodine therapy are less effective in people with higher BMIs, Morton says. Organ transplants, too, can be denied to people with BMIs over 35, he adds, out of fear that the procedures are too risky for those patients.
[See: 7 Reasons to Call Off a Surgery.]
"When you carry extra weight, the impact is on quite a few different levels," Morton says, explaining that fat flaps can be tough to work around, anesthesia breathing tubes are harder to put in, and high blood sugar levels and inflammation make patients more prone to surgical site infections. Even stitching obese patients' skin after abdominal surgery is riskier since fatty tissue doesn't heal as well as tissue with more blood vessels, and the added weight puts more stress on the wound, Cima says.
Surgeons, meanwhile, may need special tools they're less familiar with to operate on bigger patients, and health care workers are more likely to injure themselves on the job when handling obese patients, Cima said at the February conference. "It's terrible for the patient to have complications, and you want to try to reduce it at the individual level, but the real impact is at society level," he said. "Because if you can reduce the number of bad events, it's going to cost less to deliver care."
What's a Patient to Do?
While obesity does raise the risks of surgical complications, those don't always outweigh the benefits of the procedure, says Dr. Michael Parks, an orthopedic surgeon at the Hospital for Special Surgery in New York City who chairs the American Academy of Orthopaedic Surgeons Workgroup on Obesity. "Obese patients have the same mobility, pain and quality of life issues that nonobese patients have" when they seek joint replacements, says Parks, whose preliminary research has found that super obese patients -- those with BMIs over 50 -- report greater improvements in pain, stiffness and activities of daily living, and are more satisfied two years after knee replacement surgery than normal-weight patients. "We have to weigh ... their improvement in quality of life versus the potential costs," he adds.
What's more, not operating on obese patients to avoid risk or cost can backfire, Morton points out. "When you delay treatment of these patients, it gets worse," he says. While Morton says the ideal solution would be preventing obesity to begin with, one of the most important things obese patients considering elective surgeries can do is select doctors with whom they can openly discuss the effect their weight might have on the procedure. "Find a doctor who's willing to work with you, and ... not just operate on you, but engage with you, discuss with you, let you know the potential risks and benefits [and] have an open, non-judgmental conversation," Parks says. Morton suggests also looking for a hospital that's accredited in bariatric surgery, since studies show they have better outcomes for obese patients across the board.
Another step is to consider weight-loss options, experts say, whether that's as extreme as undergoing bariatric surgery -- which doesn't have the same complication rates as some other surgeries, Morton says, mostly because the teams who perform them are experienced in operating on obese patients -- or as mild as cutting out one soda a day. Meeting with a nutritionist, primary care doctor or weight-control specialist can help, too.
"Don't view this as something that's a lack of willpower -- this is a disease process; it's a biologic process that we need to address," Morton says, noting that working to control weight shouldn't carry any more stigma than addressing other surgical risk factors like high blood pressure before the procedure.
Even losing just a few pounds can help, Parks adds. "I tell many people, 'I don't expect you to come back skinny -- if you do, please let me know the secret because I want to know for myself,'" he says, noting that he, too, has struggled with his weight, "'but at least you can be empowered.'" If a 300-pound patient can lose 30 pounds before surgery, he says, "it's a win-win situation."
For Warr, who watched her sisters yo-yo diet throughout their lives without success and who's heard horror stories about bariatric surgery, weight loss wasn't an option she wanted to consider. Instead, she turned to a local university hospital's website and sent an email to an orthopedic surgeon, who successfully performed both knee replacements. "You have to be persistent, have your information, go in and keep trying," she says.
[See: 10 Lessons From Empowered Patients.]
Today, Warr spends her time volunteering at a women's shelter, reading and making plans to travel. While she'll never run a marathon, she says, she appreciates her improved mobility and lessened pain that has allowed her to run simple errands like grocery shopping without having to stop and rest every 10 minutes. Says Warr: "I'm enjoying life."