Be Careful Who You Call an Expert

Beginning Note from Dr. Q

The unfortunate thing about weight loss procedures is that, when the surgical procedure doesn’t work, the patient takes the blame.

Although bariatric surgery is common these days, and there are quite a few self-declared experts working in the field, I certainly didn’t begin my bariatric surgery program because it was popular or easy. When I first started my weight loss surgery program, it involved a huge amount of work with minimal financial reward.

During medical school, and throughout my surgical training, I was exposed to bariatric surgery. The University of Minnesota, where I attended medical school, was the first surgery department in the world to publish a report about using surgery for weight loss, in 1952. It has always been one of the leading bariatric surgery centers in the world under the guidance of a brilliant surgery professor, Henry Buchwald, who is one of the few, truly world-renowned metabolic surgeons. When I entered medical school, Dr. Buchwald had been a professor at the university for more than 25 years and was completing a landmark study on using intestinal bypass to treat high cholesterol. He was the director of the bariatric surgery program.

The first time I saw bariatric surgery performed was in 1991 when Dr. Buchwald performed a gastric bypass. I had read his research on high cholesterol and to me it was amazing to think that a fairly simple surgical procedure could have such a profound effect on a metabolic disease. The implications seemed profound.

I discussed the effects of Dr. Buchwald’s bariatric operations with some of my classmates, and with several surgical residents, and their response was that the operations were “a joke” because they were being done on “fat, lazy people” that just needed to eat less and exercise. Nobody seemed to want to discuss these operations!

My personal history had included being a fairly intense athlete for most of my life, and I had never been overweight. Since my early school years, I had spent much of my free time practicing sports, and as a result I was rarely around obese people, and had never really thought much about it. Nevertheless, I knew how hard it was to lose 10 or 20 pounds to compete in a sport, so losing 100 pounds seemed like a nearly impossible task. It made sense that, if a relatively safe operation could help a person lose that extra weight, it would be worth doing. The main resident I was working with at the time laughed at me when I mentioned this, and suggested that I consider psychiatry instead of surgery, so I simply stopped asking questions about bariatric surgery.

Two years later when I found myself at the University of Chicago training in surgery and the bariatric surgeon, Dr. John Alverdy, was an excellent clinical instructor with a large number of bariatric patients. Once again, I was exposed to bariatric surgery and this time I learned how to perform the procedures. By the end of my training, I felt comfortable evaluating patients for bariatric surgery and also felt competent in performing the gastric bypass operation. A piece of luck was that a few of the instructors in Chicago were early experts at minimally invasive (laparoscopic) surgery, and I was able to quickly pick up many of those techniques. As a result, I entered private practice with a significant amount of skill in laparoscopic surgery, and with a solid education on bariatric surgery.

In 1997 and 1998 I corrected a number of bariatric operations performed elsewhere that had resulted in patient complications. By 1999 I had assembled the appropriate team and so I started performing primary bariatric procedures myself. Due to my understanding of minimally invasive surgery, I quickly applied laparoscopic techniques to my bariatric surgery practice and began to perform essentially all my bariatric procedures using laparoscopic techniques. According to Ethicon Endosurgery (a surgical equipment manufacturer) my surgical weight loss program was one of approximately 20 surgical sites in America performing essentially 100% of their bariatric procedures with laparoscopic techniques.

At first there was significant resistance to the minimally invasive surgical procedures I began to perform. Very few physicians referred patients to me, and some were openly critical. One general surgeon told me that he had tried to do a laparoscopic appendectomy and that “it doesn’t work” so I was, apparently, wasting my time. When I scheduled the first laparoscopic splenectomy (spleen removal) in Orange County, a surgeon asked me why I was making simple procedures harder by using minimally invasive surgery. Luckily, my first laparoscopic appendectomy took 12 minutes, and my first laparoscopic splenectomy patient recovered so quickly that I discharged him the day after surgery (typical hospital recovery for traditional spleen removal was 3-4 days).

The criticism was even stronger with bariatric surgery, and the Chief of Surgery sent me a letter telling me that I was “wasting a brilliant surgical career” by operating on “fat people that are just going to drink milkshakes all day.” The Chairman of Internal Medicine stopped me in the hospital entrance one day and asked me “Are you still operating on those fatties?” And a senior hospital administrator responded to my complaint about the delay in buying bariatric equipment by saying “we really don’t want a bunch of fat people walking in here every day.”

The discouraging comments simply made me more determined, and when I thought about how much I respected the professors that had taught me bariatric surgery, all the criticism seemed insignificant. The good news is that, over time, the attitude changed and I eventually had very strong support from many physicians at the hospital.

In 2000 I attended the national conference on bariatric surgery in Nashville. I was invited to a gathering at the home of Dr. George Cowan, a past president of the bariatric surgery society, and was happy to meet many highly experienced bariatric surgeons from around the country. All of the surgeons seemed dedicated to improving the treatment for severe obesity, and to developing a better understanding of the disease. The meeting attendance was fairly small, a few hundred surgeons, but the enthusiasm was apparent.

The emergence of laparoscopic bariatric surgery was slow due to the high level of technical skill required. Most bariatric surgeons struggled with laparoscopic surgery and, after attempting the laparoscopic technique for several hours, converted most operations back to the traditional, big-incision, open surgery in order to complete the procedure safely. Then, along came the Lap-Band.

With the Lap-Band System™ there suddenly was an “easy” laparoscopic operation that could be used to treat severe obesity. Despite the growing demand for minimally invasive bariatric surgery, many patients had been dissuaded by the (false) claim that laparoscopic gastric bypass was a very high-risk procedure. Then, suddenly the Lap-Band seemed like the answer to their prayers.

Unfortunately, many unskilled surgeons with little interest in helping obese patients, saw the Lap-Band as a means of quick and easy income, and climbed on board the Lap-Band train. These surgeons promoted the operation as if the only thing needed to lose weight was placement of the band, and the flood gates opened up with patients pouring into inexperienced bariatric surgery clinics with expectations of immediate weight loss. With high patient demand and numerous minimally-trained surgeons jumping into the bariatric field, the quality of bariatric surgery, in my opinion, declined dramatically. During this time several commercial surgical clinics opened up, ran huge marketing campaigns, and hired mediocre “bariatric” surgeons to stick in Lap-Bands as fast as possible. Patients flooded these clinics and the centers made huge profits. Almost nobody was asking the question “What is the quality of surgery and the level of experience?” at these centers.

This is when bariatric surgery “became popular” and new “Experts” (at least according to their marketing) first arrived on the scene.

Fortunately, within a few years the bariatric surgery society adopted an accreditation program that supported the goal of surgical excellence and comprehensive patient support. This Center of Excellence program helped to establish quality of care parameters and enhanced the success of bariatric surgery overall. In my role as Director of Bariatric Surgery at multiple surgical institutions over the past 20 years, I have been personally instrumental in achieving Center of Excellence accreditation at six (6) hospitals.

Although mass marketing clinics still can make huge profits from high volume bariatric surgery despite having little interest in the management of patients (these centers are often not Centers of Excellence), I know of many qualified bariatric surgeons across America with excellent surgical skills and dedication to patient success. Today, awareness of the success and benefits of bariatric surgery has increased, and weight loss surgery enjoys a much higher level of support throughout the medical profession. Excellent clinics exist, staffed by true bariatric experts, and smart patients can find the help they need.

Ending Note from Dr. Q

Be careful who you go to for weight loss surgery! And be careful about signing up for new procedures that promise great weight loss with little or no risk. Many, many procedures have come and gone and few have withstood the test of time. Examples are gastric plication, various gastric balloons, and other devices. Permanent weight loss, and weight loss surgery, is not a no-brainer. The profession of weight loss is a perfect career for fakers and opportunists; after all, if the drug or the procedure doesn’t work, there is always the excuse that the patient just didn’t have enough willpower. So be careful.

Good luck to all patients, and take care.

Brian Quebbemann, MD, FACS, FASMBS

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