To Fat for Surgery?

Man do I love the UK’s National Health Service. No, I am being serious. Their struggles and suits over denying patients access to expensive drugs such as the breast cancer wonder cure Herceptin, or Alzheimer’s Disease treatment Aricept provide a truly amazing opportunity to discuss the fundamentals of medical necessity, value for cost and fairness in a publicly financed health system.

Today we are treated to the story of one Scottish woman, a Ms. Frances Kinley-Manton, who needed a hip replacement, but was repeatedly denied because she was too fat; at 210 lbs and 5’4” her BMI was 35 (halfway between obese and morbidly obese).  She tried and failed to loose the 30 pounds the doctors had required and eventually went to to Malta and paid $14,600 for the surgery. She says she was discriminated against.

Whether or not she suffered discrimination boils down to a body of controversial science on the outcomes of surgery on obese people. For example, a team of Swiss doctors led by Daniel Dindo found in 2003 that obese people (mildly or morbidly) show the same level of complications and outcomes as normal weight people when undergoing general elective surgery - such as a hip replacement.

Then again, obesity seems to increase risks with spine surgery. They are more likely to have complications during colorectal surgery. A recent review article on hip and knee replacements also indicated that morbid obesity (BMI > 40) raised the risk profile profile, but just regular obese people seemed to do okay. Their knee replacements didn’t last as long, though. Many studies have also found that obese patients are more likely to get infections from surgery.

While the literature is inconclusive about the general outcomes of surgery on obese people, what is for sure is that surgeons don’t like to operate on the them. It’s harder to see, harder to align and more work. In many studies that report no overall difference in complications/results, surgeries on obese people still took longer..which means they probably cost more, too.

Given the information available, were the doctors right to refuse her surgery until she dropped to a BMI of 31? Maybe. Were they just cost-saving as she claims? I seriously doubt it. Should she lose weight anyways? You bet your ass she should have. Would having her hip replacement actually help her lose weight (chicken-egg-chicken-egg)...not according to this one study that followed obese people after hip replacement surgery: they actually GAINED weight.

My suggestion? She should have sat back, ate 12 deep-fried Mars bars a day until she reached a BMI of 40, at which point she would have qualified for government funded bariatric surgery, which would then help her drop below the weight cut off for hip surgery and Bob’s your uncle. I know..I am brilliant.