An Interview with Kelvin Higa, MD, FACS

| October 7, 2008

What do you think expanding the society’s realm to metabolic surgery has accomplished?
Actually, it has always been about metabolic surgery. We just changed our name to be more descriptive and accurate about what we were doing. The name change has done well to focus our efforts and resolve in making access to care a primary objective. As bariatric surgery accomplishes so much to improve the health and longevity of our patients, how can we ethically stand by while insurance companies deny coverage?

How come the American Society for Metabolic and Bariatric Surgery (ASMBS) has not taken a stand on the over-representation by industry that banding is as effective as gastric bypass?
Are you sure that industry has taken this stand, or has it been the claim by individual surgeons? I think that industry has done a spectacular job of educating the public as to the disease of obesity and providing educational support for surgeons as well. Besides, if you consider resolution of comorbidities an endpoint, banding can be as effective as any other procedure and more acceptable to patients who otherwise would not consider surgery an option.

Should sleeve gastrectomy be done as a primary bariatric operation?
I stand by the ASMBS position statement, which can be viewed at www.asbs.org.

During your tenure, did your opinion about the role of psychology in bariatric surgery change at all? Do you see that role expanding or perhaps diminishing in the coming years? And what do you think about the role of psychology and revisional surgeries?
I think that the use of psychological evaluations as a barrier to care is ethically wrong. My views regarding the value of psychological support have not changed in the 18 years I have practiced bariatric surgery. I feel that the role of psychologists/therapists should expand, only hampered by reimbursement issues, as an important part of the interdisciplinary team our patients deserve.

What were the most rewarding and the most disappointing aspects of being ASMBS President?
The most rewarding aspect of this job is the camaraderie shared among the executive officers and members of this organization. I have never felt so privileged as in this association; the ethics, hard work, and selflessness of this council defy words.
The only disappointment is in not completing the job—there is so much work to be done.

Having been ASMBS president, do you now have interest in pursuing higher offices such as Governor of California or President of the US?
Absolutely not. It is one thing to work with surgeons who may have differences of opinion, but have a singular focus; can you imagine working with politicians? I am afraid the sacrifice would be too great.

How can we assure access to bariatric surgery for those who need it?
This will require a change in public opinion that drives legislation. Already, bariatric surgery is one of the few therapies that delivers a return on investment. Coverage of bariatric surgery will actually be cheaper for an insurance company and society than treating the ongoing medical problems caused by obesity. Ethical, scientific, and financial forces should dictate universal access to bariatric surgery: Wake up, America!

If we had a drug that reversed diabetes, asthma, hypertension, cardiopulmonary failure, and assured durable weight loss, would we be satisfied if only one percent of the afflicted could get it?
What if only the affluent had access to it? Isn’t that the issue today? The very patients who need our services do not have access: the uninsured, or poorly insured.

In 2008, in Chapter 25 on page 219 of the book you and others edited called Obesity Surgery, you wrote that, “Interestingly, short-term data appears to be superior to ‘open’ standard gastric bypass series suggesting a subtle difference in the anatomical construct of the laparoscopic procedures.” You have had few leaks from the gastroenterostomy in the 6000 operations reported (8000 now?) Could this be due to there being no knots tied over the anastomotic line? You have described two running rows of absorbable suture, each tied to its corresponding end. This would eliminate the necrosis of tissue incorporated in a ligature of tissue such as would usually be present at the beginning and end of most running sutures and at every site of an interrupted suture. Running sutures spread the tension throughout the encompassed tissue, which should allow for swelling with less risk of necrosis, and would seem to decrease the risk of leak from necrosis of tissue. Could this be one of the suggested subtleties? How many surgeons use this technique? Does laparoscopic enlargement of the scene, and instrument tying, result in less force in tightening the running suture and knots?
I was simply referring to an observation that I cannot prove. In order to test this hypothesis, that laparoscopic surgery is superior to open surgery, it would require a prospective, randomized study, which simply cannot be performed today. Who would sign up for an open surgery? There are many aspects to manual anastomosis, all of which are important. Tension, blood supply, and tissue trauma are all part of “technique,” which is vague and ill defined. Every surgeon believes they have good technique, but will have trouble telling what exactly technique is.

What is your explanation for the cure of type 2 diabetes (T2D) by both intestinal and gastric bypass? Do you treat T2D with Byetta before resorting to Roux-en-Y gastric bypass (RYGB)? Would you consider prolonged and effective medical treatment in preference to RYGB for a patient with T2D whose BMI was less than 40? That was one of the recommendations of the March 2008 meeting in Rome regarding surgical operations for diabetes.
I do not treat T2D independent of obesity. Although there is research in this regard, it is premature for individuals to do so outside of a scientific study. That being said, if one of my family members had a BMI of 30 to 35 and T2D, I would offer them surgery. I wish I had an explanation of why surgeries of such different mechanisms control diabetes so well. Even though we can imagine such interesting pathways, still there is a major change in food acquisition and processing with every operation.

Have you seen any patients with a RYGB who lost consciousness from prolonged overstimulation from endogenous GLP-1 with consequent hyperinsulinemic hypoglycemia and needed partial pancreatectomy? Having 8,000 patients, there would seem to be an opportunity to determine the frequency of this and other complications.
I have not and I am looking for this patient. I really like operating on the pancreas.

Should all patients be treated with the same operation? Why are there so many different operations? You have written that patients are reluctant to return and pay for visits when they feel well. Osteopenia can be asymptomatic until bones break. How can we determine the important lifelong effects of these operations and protect patients from known complications?
One size does not fit all. It is interesting how our operations are converging as far as efficiency, safety, and efficacy. How do we protect patients from the lifelong effects of malnutrition? Osteopenia has been a problem long before bariatric surgery. Lifelong follow-up is not just for complications of the operation. Obesity is incurable. Follow-up is necessary simply because of this fact. Follow-up is important in any chronic disease.

We have seen a great deal of movement during your tenure with regard to showing the positive impact of bariatric surgery on type 2 diabetes (e.g., the JAMA paper by Dixon et al, 60 Minutes segment). This is information generally known by bariatric surgeons for a very long time. Do you think the non-surgeon practitioners, such as endocrinologists and family practice doctors, now recognize surgery as a first-line type of treatment of T2D in the morbidly obese?
Although the research has been vital, most physicians respond to anecdotal experience. If one patient had a bad outcome, all operations are bad. If patients do well, they are often lost to the endocrinologist and they never see the end result. When internists, family doctors, cardiologists, and orthopedic surgeons are involved with care, they are ecstatic about the results and are supportive of surgery. However, I have never received a referral from an endocrinologist in the 18 years that I have been practicing bariatric surgery. It is interesting that only the physicians who take care of the complications of diabetes are supportive, while those that treat diabetes are not.

What was the biggest solved obstacle to care you faced within your tenure?
The relationship between the ASMBS and International Federation for the Surgery of Obesity (IFSO) has been strained over the past few years. We have really made progress in uniting these two great organizations. The ASMBS and IFSO are co-sponsoring meetings and MAL Fobi has been named the next president of IFSO.

What was the biggest unsolved obstacle to care within your tenure?
I have failed to resolve the problems of access, especially for the rural patient. Although CMS has embraced bariatric surgery, the number of Medicare patients has decreased due in part to lack of access to a center. Many surgeons who have diligently served these patients can no longer practice bariatric surgery.

What are you most proud of when you look back on your tenure?
I am proud of the sacrifices my family made and how supportive they were knowing the importance of this job.

What recent discovery (ies) surrounding obesity do you feel will alter future method of treatment in patients?
It’s all about satiety. If we can impart satiety without an anatomic change, then we will really have something.

Where do you see bariatric surgery in 10 years? What percentage rate of growth do you foresee?
Bariatric surgery will continue to grow. The number of centers will increase. Procedures and techniques as well as outcomes will become standardized. We will offer surgery to smaller BMIs as safety improves. The biggest obstacle we will face will be in the training of qualified surgeons to meet the demand.

Category: Interviews

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