Medicare is considering whether to provide blanket coverage for obesity surgery instead of continuing to consider cases individually.

Two major studies in Wednesday's issue of the Journal of the American Medical Association are the first to address the operation's safety. The results provide some reassurance while raising new questions about a higher death rate among high-risk Medicare patients and the danger of post-surgical complications for all patients.

Among Medicare recipients, who make up less than 10 percent of all gastric bypass patients, 2 percent had died 30 days after the operation and 4.6 percent had died after one year, said Dr. David R. Flum of the University of Washington, who headed the study. Among patients 65 and older, 11.1 percent had died after one year.

But Medicare patients tend to be older and sicker than the average person undergoing the surgery, according to Flum, whose study included 16,155 patients across the country who had the operation from 1997 through 2002. Their average age was 48 years.

Flum called the results "a reality check."

"I do this operation," said Flum, noting that obesity is one of the leading killers of Americans. "I believe that this operation is important and a potentially life-saving thing for patients with extreme obesity.... But this surgery is not for everybody. It's not a vanity operation. This is a real operation with real risks and huge upside benefits."

Flum's study found that Medicare patients with the highest risk of mortality after surgery were older men and were operated on by surgeons with the least experience in performing gastric bypass procedures.

Surgical Complications

The second study, which looked at a broader population, found a much lower one-year mortality rate: 0.91 percent. It looked at 60,077 California residents, with an average age of 42.2 years, who underwent surgery for obesity from 1995 through 2004.

But that study also found that the hospitalization rate of patients up to three years after bypass surgery was twice as high as the rate during the three years before the operation.

Surgical complications were the main reasons for hospital re-admissions, followed by cosmetic surgery to remove sagging skin after patients lost weight, said Dr. David S. Zingmond of the University of California, Los Angeles, who headed the study.

"The risks of gastric bypass surgery may be similar to those of other types of abdominal surgery, but in this case it's an elective procedure," he said. "They have a choice about whether or not they want to undertake that risk."

When Madalyn "Midge" Ruhl of Indian Head Park, Ill., had her gastric bypass surgery at Rush University Medical Center 21 months ago, she was aware of the risk of dying but felt it was small.

"I completely discounted that because what's the alternative?" she said. "If I continued to eat like I was I'd be dead."

Ruhl, who saw her weight drop from 304 pounds to 180, said she was home from the hospital in a day and a half and had no medical complications. "It was life-changing for me. Stairs are not a threat. Parking lots are not a threat. I'm doing the day-to-day things that I was shying away from before."

Huge Improvement in Quality of Life

One positive finding from the California study was a nearly 50 percent decline in hospital admissions for heart problems after surgery compared with the year preceding surgery, Zingmond said. The rate dropped from a little less than 2 percent of patients to about 1 percent.

Previous studies have shown that people undergoing gastric bypass procedures lost an average of 61 percent of their excess weight and saw other weight-related conditions, such as diabetes and high blood pressure, either disappear or improve.

The studies appear at a time when Medicare is considering whether to provide blanket coverage for obesity surgery. Cases are now considered individually. Private medical insurance covers more than 80 percent of non-Medicare patients undergoing the surgery, which is estimated to cost between $25,000 and $50,000.

"These studies have to be taken with a grain of salt," said Dr. Edward Livingston, chief of gastrointestinal surgery at the University of Texas Southwestern Medical Center, who frequently performs gastric bypass surgery. "My concern is that policy people are going to react to them without considering the whole picture for these operations.

"If [patients'] diabetes goes away, which it usually does, and if their hypertension gets better or their sleep apnea goes away, that won't be captured in those kinds of studies," he said. "These patients have a huge improvement in their quality of life."

The studies furthermore do not include the results of the newer, less invasive laparoscopic surgery in which a surgeon partitions the stomach through a series of small holes in the abdomen, Flum said. These patients often are released from the hospital within 24 hours and have fewer complications, he said.

In an accompanying JAMA article, Dr. Heena Santry of the University of Chicago Hospitals estimates that 130,000 weight-loss operations will be performed this year in the United States, a tenfold increase since 1998. By 2010, the number is expected to increase to 218,000 procedures.