A gastric bypass surgeon in Riverside has been accused by state medical regulators of mishandling the care of 11 patients, including six who died, casting a harsh spotlight on the possible risks of a burgeoning -- and lucrative -- enterprise embraced by many California hospitals.
Dr. Terry Sanderfer exhibited gross negligence and incompetence by failing to properly care for leaking organs, severe infections and other post-surgical complications, according to the accusation filed earlier this summer by the Medical Board of California.
The case comes as the popularity of weight loss, or "bariatric," surgery is surging and more hospitals and surgeons are rushing to offer the procedures. Some surgery experts and insurers are concerned that inexperienced hospitals and inadequately trained surgeons are taking on the operations, which even in skilled hands can result in complications.
"We need to brace ourselves as a surgical community for the chance that we're going to see more and more adverse outcomes as more and more people come to the field with varying levels of training," said Dr. David Flum, a gastrointestinal surgeon at the University of Washington School of Medicine in Seattle.
Shortly after the deaths among Sanderfer's patients, which occurred after operations at three Riverside County hospitals between 2000 and 2003, one of the hospitals -- Riverside Community Hospital -- canceled such operations altogether, citing the risks. Another, Corona Regional Medical Center, has not done such surgeries for months, although it has not formally ended the practice.
And Sanderfer himself, who had performed hundreds of gastric bypass procedures for 14 years and is the subject of some glowing testimonials on the Internet, has quit doing them. Through his attorney, he denied wrongdoing but said he couldn't afford an increase in his malpractice premiums.
Sanderfer, a general surgeon who continues to perform other types of abdominal operations, has faced 21 malpractice suits in recent years alleging deficiencies in gastric bypass surgeries, his attorney, James Kjar, confirmed. In three cases, his insurance has paid a total of $1.3 million in settlements, without admitting any wrongdoing. Thirteen cases are pending, and other cases have been dismissed, Kjar said.
"Dr. Sanderfer does not believe there was any delay or any substandard care" in any of the cases, Kjar said, adding that experts have reviewed Sanderfer's care and found that his actions were "appropriate, within community standards and not negligent."
"Bariatric patients, because of their morbid obesity, have one of the highest complication and death rates of any elective surgical patients," Kjar said. "And all of these patients signed documents indicating that they ... accepted those risks."
The procedures do come with established risks. Flum and his colleagues published a study last year looking at bariatric surgeries in Washington state over 15 years, finding that one in 50 patients died within 30 days.
"People who are considering the surgery have to go in with their eyes open," he said. "This is not a cosmetic operation by any means. It's major abdominal surgery performed on patients at high risk."
Several hospitals have stopped or suspended the procedures after high-profile deaths, including, last year, Iowa Methodist Medical Center in Des Moines and the University of New Mexico hospital in Albuquerque.
Bariatric surgeries are still performed relatively infrequently compared with other types of operations, Flum said. About 140,000 were done in 2004, according to the American Society of Bariatric Surgery, compared with between 700,000 and 800,000 gallbladder operations annually.
The procedures are for patients so obese that they are unable to consistently lose weight by dieting and exercise alone. Gastric bypass, one of the more popular approaches, involves creating a small pouch out of the stomach, and directly attaching it to the small intestine. The new stomach can't take in as much food, and the intestine can't absorb as many calories.
But the number of bariatric surgeries has nearly quadrupled since 2000, their popularity fueled by high-profile successes such as that of pop singer Carnie Wilson, who had her procedure broadcast on the Internet, NBC "Today" show weatherman Al Roker and "American Idol" judge Randy Jackson.
The procedures -- which cost an average of about $25,000, not including treatment for complications -- have also become profit centers for financially strapped hospitals. Nationally, some health and malpractice insurers have balked at coverage, citing costs and risks, but HMOs in California are required to cover operations that doctors deem medically necessary.
Done effectively, such surgeries can significantly improve or eliminate conditions associated with obesity, such as diabetes, high blood pressure, sleep apnea and liver disease, said Dr. Harvey Sugerman, last year's president of the American Society for Bariatric Surgery. Some "patients need this operation," Sugerman said. "It works."
But a Rand Corp. study found that about one in five cases results in complications. Although most are minor, the more serious involve intestinal leaks and blood clots, and some patients die as a result. The mortality rate has been reported at less than 1% to 3%, depending on the study. By comparison, the death rate for cardiac bypass surgery is about 2.6%.
Complications have declined as more hospitals have gained experience, but national experts say they are increasingly concerned about facilities without significant streams of patients or well-established programs.
"You have to train nurses, radiologists, anesthesiologists, physical therapists. You have to have proper equipment, operating room equipment. And then you need surgeons and other medical specialists adequately trained to deal with the morbidly obese patients," said Dr. David Provost, director of the Clinical Center for the Surgical Management of Obesity at the University of Texas Southwestern Medical Center.
There is no legal requirement, however, that surgeons who perform the operation receive special bariatric training. Some medical societies and insurers are proposing measures that would allow some hospitals to be certified as "centers of excellence," but meeting such criteria would be voluntary.
At Riverside Community, Sanderfer was the only doctor performing weight loss surgery, and he was one of two surgeons doing the procedure at Corona Regional. He helped establish the program at Parkview Community Hospital in Riverside.
A Riverside Community spokeswoman said the hospital discontinued the surgeries because of the potential risks demonstrated nationally. Parkview officials declined to comment.
At Corona Regional, an official said the hospital never intended to run a full-fledged program.
"I understand that you had to do a critical number of procedures to have an effective program," said John Calderone, the hospital's chief executive. "And we just never had that opportunity here; we never were interested in that product line."
Sanderfer's attorney, Kjar, said the doctor had performed more than 1,500 gastric bypass surgeries since 1990, with 13 deaths in that time -- well within reasonable limits, he said.
Sanderfer, 58, completed his residency in general surgery in 1983 and was recertified by the American Board of Surgery in 1998. Kjar said Sanderfer spent several weeks in 1990 learning the most common gastric bypass procedure under a nationally recognized specialist in the field. He has updated his knowledge annually at conferences, Kjar said.
Sanderfer is entitled to a hearing before an administrative law judge, who then will make a recommendation to a Medical Board panel. Any sanction -- up to and including license revocation -- can be appealed to the state courts.
The Medical Board accusation points to 42 instances in which Sanderfer allegedly mismanaged the care of 11 patients. The most serious involve post-surgical care. In one case, the Medical Board accused Sanderfer of delaying postoperative treatment of 24-year-old Felicia Miars, whose organs leaked infected fluid into her abdominal cavity. The board said that Sanderfer delayed draining the fluid at least twice and that he did not return Miars to the operating room at Corona Regional when he should have.
"She started having troubles right away, fever," said her father, Carlos Mendoza, 72. "I just don't think he followed up soon enough. She kept doing worse and worse."
She died a few weeks after the operation.
"Gosh," Mendoza said of Sanderfer, "he shouldn't be doing these operations."
In another case, the Medical Board accused Sanderfer of releasing a 400-pound 37-year-old patient from Riverside Community before he was stable. The patient, who was identified only by his initials, S.F., ultimately had a heart attack and died. An autopsy found that the surgical connection between the stomach pouch and the small intestine had broken down and that fluid had spilled into the abdominal area, the accusation said.
Some of Sanderfer's patients swear by his dedication and skill. Susan Cavano, 48, weighed nearly 300 pounds before her surgery in December 2001 at Riverside Community.
"I had excellent care; he was in there to see me every day," Cavano said. "I never had one single problem with him at all."
She said she was given excellent follow-up care, as well. Cavano said there were no complications with her gastric bypass surgery.
"The surgery was a success -- I'm healthy," she said. "I probably would have died without it."
Times staff writer Charles Ornstein contributed to this report.