Large study shows high BMI not associated with serious top-surgery complications

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I’ve written quite a lot about BMI-based procedure denials for higher-weight patients. These denials typically amount to a patient having their healthcare held hostage for a weight loss ransom that they are very unlikely to be able to pay.

I wrote about fighting these denials in a two-part series here

I have a collection of resources to fight joint surgery denials here

I have a collection of resources to fight gender-affirming surgery denials here

Now I have another study to add to that collection.

A group of researchers at Johns Hopkins published a study on November 1 (Hassan et al, Association of High Body Mass Index With Postoperative Complications After Chest Masculinization Surgery) that looks at complication rates in transgender and nonbinary patients undergoing chest masculinization surgery (often called top surgery).

The conclusion was that “Chest masculinization surgery [CMS] remains a safe option for TGNB patients and may be safe to perform in patients with higher BMI. The informed decision-making process between surgeons and their patients should clearly delineate the potential risks associated with higher BMI and the negligible overall incidence of significantly morbid complications.”

Let’s dig into this.

Some basics:

The study utilized data on 2,317 transgender and nonbinary patients from the National Surgical Quality Improvement Program (NSQIP) 2012–2020. The primary outcome they looked at was incidence of at least one complication within 30 days. The secondary outcomes they looked at were incidence of major and minor complications.

Major complications included “cardiac arrest requiring cardiopulmonary resuscitation, myocardial infarction (MI), stroke, acute renal failure, unplanned intubation, pulmonary embolism (PE), deep venous thrombosis (DVT), sepsis, septic shock, bleeding requiring transfusion, unplanned reoperation, unplanned readmission within 30 days, as well as prolonged hospital stay beyond this period. Minor complications included surgical site infection (SSI), urinary tract infection (UTI), pneumonia, and wound disruption without reoperation.”

They classed BMI (with, as always, a reminder that it is a deeply problematic measure) as 0 (<30), 1 (30–34.9), 2 (35–39.9), 3 (40–44.9), 4 (45–49.9), and 5 (≥50).

The study population included

Category 0: 1501 participants

Category 1: 461 participants

Category 2: 208 participants

Category 3: 95 participants

Category 4: 26 participants

Category 5: 26 participants

Chest wall masculinization was defined as any mastectomy procedure performed among TGNB patients with or without nipple/areola reconstruction.

I also want to say that this study is very well written and presented, often these studies are dense and difficult to parse, even for someone with expertise. I feel like this study (though, annoyingly, it is behind a paywall) is particularly clear and easier to read, even if someone were less used to reading medical research so I want to acknowledge the authors for that.

Ok, let's talk about what they found:

Those in category 5 had a significantly higher risk of having at least one complication (15.5%) compared with patients with BMI categories 0 (3.7%) and 1 (2%). (Though it’s interesting to note that those in category 1 who are considered “ob*se” had a lower incidence than those in category 0 who are classified as “non-ob*se.”)  Those in category 5 also had a significantly greater incidence of UTI (3.8%)and bleeding requiring transfusion (3.8%) compared with patients in category 0 0.2% for bleeding, .1% for UTI) and category 1 (who, again faired better than category 0) at 0.0%.

They point out that “Across BMI categories, there was no significant difference in the odds of unplanned reoperation, sepsis, bleeding requiring transfusion, or wound disruption without reoperation.”

Further, they explain that “It remains clinically reassuring that none of the patients that developed postoperative SSI required unplanned reoperation, regardless of BMI. Hematoma was the most common indication for unplanned reoperation and did not significantly differ across BMI categories in our study. This is consistent with other retrospective studies by Rothenberg et aland Cuccolo et al.”

The also found that “Our results suggest that while increasing BMI is associated with the development of postoperative complications after CMS, the overall likelihood of life-threatening and significantly morbid complications is negligible. We recommend re-evaluation of BMI cutoffs for CMS patients. It would benefit surgeons and their patients to discuss the increased risk profile for unplanned readmission, UTI, and SSI in patients with high BMI as part of the informed decision-making process; however, the risk for life-threatening complications such as PE and cardiac arrest remains low.”

This is important because there are serious risks for refusing these surgeries or demanding weight loss in order to get them as the study authors point out:

“Chest masculinization surgery is the most common surgical procedure performed for TGNB patients and has been shown to drastically improve quality of life…Despite the physical, mental, and psychosocial benefits of gender-affirming surgery for TGNB patients, transmasculine patients seeking CMS can be denied surgery because of BMI requirements implemented to mitigate the potential risk for intraoperative and postoperative complications.”

They continue:

“Body mass index requirements that lead to prescriptive dieting and weight loss can potentially worsen health outcomes and disordered eating behaviors. This is particularly relevant for the TGNB patient population who are more likely to develop disordered eating behaviors compared with their cisgender counterparts. The use of BMI to restrict access to surgery can also potentially worsen preexisting health disparities within the TGNB population, as non-Hispanic Black patients have higher BMI compared with Hispanic and non-Hispanic White patients, on average. The use of BMI as a barrier to care can thus intensify preexisting racial health disparities within the TGNB population.”

The authors point out that the study does have limitations including relatively low numbers in higher BMI categories, the fact that it is retrospective, and that the follow-up was only one month meaning that long-term outcome information could not be assessed. Though they point out that “Nonetheless, we were able to appropriately assess major complications, which are most likely to occur within the short-term period or less than 30 days after surgery.” They also point out that the analysis is limited by variables not including in the NSQIP including gender-affirming testosterone use.

A limitation that they don’t include but I will is an uncritical basis in the weight-centric paradigm. For example, they claim that following surgery, patients can “make significant progress in weight loss efforts” but the single study they cite to support (Brownstone, et al, Body Mass Index Requirements for Gender-Affirming Surgeries Are Not Empirically Based) says nothing of the kind. In fact, it is quite honest that:

“there is minimal empirical evidence that dieting and weight loss programs are effective for achieving significant and sustained weight-related outcomes, and this has been specifically found in a sample of TGNC individuals denied GAS who were not able to gain eligibility through behavioral weight loss programming. Rather, patients who engage in dieting have been shown to gain significantly more weight than nondieters in the long and short term, contributing to a dangerous pattern of body weight destabilization known as weight cycling. Weight cycling is strongly associated with multiple negative health outcomes, including all-cause mortality, cardiovascular disease, immunosuppression, reduced bone mineral density, and chronic inflammation.”

In this study and beyond, I want to point out that when we talk about complication rates for higher-weight patients, we always have to take care before placing the blame on body size itself. That is because of the tremendous amount of weight stigma higher-weight patients face (including not just practitioner bias, but also structural weight stigma.) Surgeries are done using equipment and best practices that were typically developed for thin patients. Many med schools don’t even utilize higher-weight cadavers, meaning that students have less exposure to higher-weight patients throughout their education. There are also simply fewer people at the highest weights meaning that surgeons and anesthesiologists are less likely to encounter them. This is likely exacerbated by the fact surgeons are simply allowed to refuse to treat these patients. Similarly, post-surgical care is often not created/optimized for higher-weight patients. A dangerous form of weight stigma happens when patients’ bodies are blamed for these inequalities in care, thus allowing the onus to be put on patients to change their bodies rather than healthcare to accommodate patients of all sizes.

For example, regarding the higher rate of UTIs among category 5 patients the study authors say “We speculate that the longer operating time required for higher BMI patients may contribute to greater odds of postoperative UTI. Because long procedures require Foley catheterization or postoperative straight catheterization, these patients may be at greater risk for developing a UTI. Further studies are needed to corroborate this notion.”

That could be the case and I appreciate their point on the need for further studies. I would like those studies to consider weight stigma as well. It’s possible that operating times could be reduced by creating techniques and equipment specifically for higher-weight people, and by surgeons having more practice time (perhaps with higher-weight patient simulators.) It’s also possible that the increase in UTIs could be (at least in part) due to higher-weight patients having a longer duration of post-surgical catheterization because the facility doesn’t have the proper equipment to help them access and use a bathroom or commode (which could everything from lifts to high-weight-rated, tall and wide toilets and commodes) or the staff doesn’t have the time and/or desire to use that equipment, requiring and/or preferring to keep patients catheterized (especially given horrifying research findings around doctors and nurses saying that they would prefer not to treat/touch higher-weight patients.)

That said, I am heartened by their recommendation and I would like to see more studies like this around BMI-based surgical denials. I also think that the mention of shared decision-making conversations is such an important point. The idea that if fat people may have higher complication rates than, or won’t have the exact same outcomes as, thinner people then they don’t deserve any care at all is deeply troubling. Not just because fat people are highly unlikely to become thin people (though that’s absolutely true) but because it leads to a vicious cycle wherein the healthcare system creates weight stigma and care inequalities, blames the negative impacts of weight stigma and care inequalities on fat patients’ bodies, then uses those negative impacts to justify more weight stigma and care inequalities.

In some cases this can be solved at the provider level – which is to say that surgeons can stop refusing to care for higher-weight patients. The idea that this patient might be more complicated/take more time/be less profitable should not be a justification for denied care. But this also requires systemic change in that firstly, our healthcare system in the US is for profit and given the amount of weight stigma that exists, surgeons who decide that fat patients aren’t worth the time/effort are largely supported. Second, surgeons are often judged internally (including in terms of pay and promotion) on their “stats” – their rates of complication and outcomes. The expected rates of complications and outcomes are typically based on thin patients. This means that surgeons are literally incentivized to deny care to patients who they feel may have higher complication rates or worse outcomes.

The system has to change from one that is built for, and prioritizes, thin bodies, to one that is built for bodies of all sizes and prioritizes equitable care for all. It’s reasonable for surgeons to have informed consent and shared decision-making conversations with patients about possibly higher complication rates, including creating plans to help reduce risk and/or for how to handle them should they occur.  It is not reasonable to hold higher-weight patients’ healthcare hostage for a weight loss ransom.

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More research and resources:
https://haeshealthsheets.com/resources/

*Note on language: I use “fat” as a neutral descriptor as used by the fat activist community, I use “ob*se” and “overw*ight” to acknowledge that these are terms that were created to medicalize and pathologize fat bodies, with roots in racism and specifically anti-Blackness. Please read Sabrina Strings Fearing the Black Body – the Racial Origins of Fat Phobia and Da’Shaun Harrison Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this.