An Interview with Alan C. Wittgrove, MD

To what do you attribute the growth of obesity in our population?

Dr. Wittgrove: Obesity is such a complex disease. It is certainly rooted in genetics, but there are so many environmental issues that influence the overall expression of the genetic potential. The fact that we are less active and have more carbohydrates in our diet does not help. I believe that if you are so genetically encoded and you get about 40 percent over your ideal body weight, you no longer have the physiologic feedback of satiety and that makes it impossible (or nearly impossible) to stay on a diet unless you receive the tool of surgical intervention.

How did you become involved in bariatric surgery?

Dr. Wittgrove: I did my medical school training at the University of Missouri at Columbia Missouri. I was very fortunate to have Dr. Boyd Terry as staff and he, of course, was one of the surgeons who did early work in bariatric surgery. I think I had some of Dr. Terry’s empathy rub off on me. I completed my residency in general surgery in the Navy and served a total of 10 years. I quickly learned that even though the jejunoileal bypass had its limitations, so many medical conditions could be treated by bariatric surgery. When I got out of the Navy in 1986 I decided to offer bariatric surgery in my general surgery practice in San Diego.

How many operations have you performed?

Dr. Wittgrove: I performed about 500 biliopancreatic diversions or mal-absorptive operations in the late 1980s and early 1990s. I have done some laparoscopic bands under the FDA study.

My primary operation is the proximal gastric bypass. I just started doing the gastric bypass open (via a laparotomy) in the early 1990s. I did the first laparoscopic gastric bypass in 1993. I have performed more than 2,500 open and over 3,000 laparoscopic gastric bypasses.

How would you characterize the current state of funding for obesity research and specifically bariatric surgery?

Dr. Wittgrove: The current state of funding is quite honestly an embarrassment! Obesity is the nation’s most important health issue and it’s treated like it’s only an inconvenience

What was the atmosphere in the medical community with regard to weight loss surgery when you became involved?

Dr. Wittgrove: Well! The medical community was very skeptical, to put it nicely. In fact, some of the medical community remains that way even today. In so many ways that is a real shame, but interestingly, it was their harsh skepticism that pushed me to keep my data in such a compulsive fashion. I know that any complication would be scrutinized and therefore I wanted to be sure the entire story was told. Bariatric surgeons were viewed as “snake oil salesmen.” Results were the same as they are today, except the operations were not done laparoscopically, of course. As more data is published, thank goodness, the medical community is beginning to understand the positive changes we create.

What do you think about the discoveries surrounding obesity and the growth of national interest in bariatric surgery as a viable option for morbid obesity?

Dr. Wittgrove: Certainly there is more of an interest in the disease of morbid obesity and the surgical treatment now versus 10 years ago. The problem is that there is still not enough interest. The NIH spends very few dollars on research in this very important health consideration.

Without proper funding, it is very difficult to do the studies that are really needed. Clearly, the surgical option is the only viable option available to patients who now suffer from morbid obesity, but there is still a stigma for some reason.

You are known as one of the most respected professionals in bariatrics and have been able to witness the evolution of obesity as a disease and surgery as a solution. How has the surgery itself progressed and changed over time, and how has this progression affected your career?

Dr. Wittgrove: I thank you for the representation. I think it is interesting that I have changed the operation very little (other than the laparoscopic adaptation) since the late 1980s. The operation has just been “studied” and “reported on” better over the years. There has been a clear upsurge in interest in bariatric surgery with the laparoscopic techniques and with certain celebrities being done but the operation is nearly the same. The important thing to remember is that surgery is the only answer for now, and we only help less than one percent of the individuals who suffer.

What is needed in the field of bariatrics to improve patient outcomes and options?

Dr. Wittgrove: I think we need to concentrate on Centers of Excellence (COE). We need to stop trying to do bariatric surgery in every hospital in every city and we need to do it with better outcomes in fewer locations.

How did you arrive at the conclusion that a laparoscopic gastric bypass could be done laparoscopically?

Dr. Wittgrove: In 1993, I was working with Ethicon EndoSurgery on some other laparoscopic procedures. I was studying with some other practices in Europe doing advanced laparoscopic work and I came to a conclusion: We can do this.

Why did we even originally think to do it? We were looking at our outcomes of our open bariatric cases and found our highest complication rate to be 16 percent and that was for incisional hernias. We thought we could save 16 percent of our patients another operation if we could solve this problem. The solution was the use of small incisions of the midline and, therefore the minimally invasive technique. In 1993, Ethicon developed the 21mm circular staples in a sealed device that was the anastomotic size we used via the open technique, so it was the most logical adaptation using our very small, 15cc pouch.

If you could change one thing about obesity treatment as it currently exists, what would it be?

Dr. Wittgrove: Currently, I believe the surgical options are very effective. I would love to see more funding so we could perform the research to answer some of those great questions we all ask time and time again. I wish people of size could get treatment for their disease as others seek treatment for other diseases and not suffer from public discrimination and embarrassment. I also wish we could concentrate our treatment in COEs so that the malpractice issues would no longer act as an impediment to access. Certainly there is no one thing I would like changed since I would also have to add to this list the need for improvement in insurance coverage: Health insurance limits access to care for so many people of size who suffer so greatly.

Are you a proponent of one over the other—open versus laparoscopic surgery?

Dr. Wittgrove: I am a proponent for laparoscopic surgery. It is more technically demanding but, done skillfully, it offers the patients many advantages. It is important to perform a sound bariatric operation even though it may be more difficult at times. One can not shortcut the operation simply to do it via minimally invasive techniques. I think creating a small pouch is the part of the operation that many find the most difficult, but I think it is very important.

What can current surgeons and others in the field do to better help the bariatric surgery patient?

Dr. Wittgrove: We can all advocate for the individuals who suffer from this dreadful disease that kills so many and maims so many more. We need to ensure that we perform surgery expertly within a program that offers a full range of services to our patients. I also believe working toward Centers of Excellence is integral to obtaining quality improvement and data accumulation.

What advice would you give to the medical student whose plan is to enter bariatric surgery?

Dr. Wittgrove: I think in most instances residents are not fully equipped to treat bariatric patients. I believe fellowships are very important and that if residents are going to come right out and primarily perform bariatric surgery, they should join a well established group to best ensure quality of care.

Do you think bariatric nursing certification is necessary?

Dr. Wittgrove: Specialized nurs-

When the specialty of bariatric surgery was quite small, we knew everyone and we knew of others’ practices. As the numbers have grown,ing care is very important and special certification is a natural progression. When the specialty of bariatric surgery was quite small, we knew everyone and we knew of others’ practices. As the numbers have grown, certification has become a necessary component to better insure education, commitment, and quality of care. Specialized nursing at the bedside is imperative for optimal patient care. I think in most instances RESIDENTS ARE NOT FULLY EQUIPPED to treat bariatric patients.

How do you typically spend your free time?

Dr. Wittgrove: I enjoy nature very much. I enjoy my work but try to balance it with working out, tennis, and time with family and friends. I have two children who are older and on their own as well as two still in their teens. The younger two are lights in my life and I try to be a positive influence in their lives.

How do you feel about the current insurance climate toward bariatric surgery?

Dr. Wittgrove: The insurance situation is obviously very complex. I strongly believe it needs to change so that more patients can have access to the only known long-term treatment of their disease. Insurance companies in general need to take the approach that I believe Blue Shield of California has taken. They believe in the treatment power of bariatric surgery and they realize complications are very expensive in many ways. They have worked to identify a group of bariatric surgeons based more on quality rather than simply trying to identify surgeons who will take the lowest price.

What do you think should be considered in this process of establishing and evaluating the criteria for the Centers of Excellence?

Dr. Wittgrove: I feel very strongly about Centers of Excellence. I am proud to be one of the founders of the Surgical Review Corporation and I serve on its board. We have worked hard to try to include all the stakeholders in the process to better understand the issues and meet them head on. We have practicing bariatric surgeons reviewing programs to better insure practicality as well as quality. I would like to see one accreditation body so that the process is not so onerous on the individual surgeon or program. Having each insurance company issuing its own COEs is redundant, expensive, and usually based more on price than quality since a site visit is rarely, if ever, done.

What were the early obstacles to success in bariatric surgery?

Dr. Wittgrove: Certainly the instrumentation has improved over the years. This is primarily in the increased instrument length that allows us to avoid excessive torque on the instruments. Better graspers have been developed, as have more efficient suturing devices. Most recently have come the devices to assist in fascial closure, which will more accurately place sutures without risk to the surgeon or the assistant. There was never a real ethical obstacle as we for me in school I have always been proud to have her in that profession. My younger two (girl, 16 and boy, 14) are still at home, and I’m looking forward to taking my daughter this spring to look at colleges. I am blessed that they are all healthy, bright, honest, and hardworking individuals.

If you had to do it all again, would you do anything differently?

Dr. Wittgrove: This question caused me to reflect for quite some time. I know I could take this in a very global way and talk about my professional self. In that regard I would have to say, “Overall—no.” I feel as though my training in the Navy was as good as it gets. It prepared me for most things that can come up. My chief of service was I have learned that bariatric surgery is high on plaintiff lawyers’ lists. It does seem

THAT NEARLY ANY COMPLICATION IS AT RISK OF A SUIT and that realistic informed consent is very important.

were always doing the same operation. There were one or two “academic” surgeons who dabbled in bariatric surgery; they came from a well known university and made a lot of money at the expense of several bariatric surgeons. The end result has been that bariatric surgery is more visible on the legal radar screen and malpractice premiums have gone up dramatically. In some locations, bariatric surgeons are no longer able to obtain malpractice insurance. The ASBS understood this threat to its membership and assisted in the development of Novus. It is my hope that Novus is the insurance answer for many bariatric surgeons.

Do you have children and/or grandchildren whom you see often?

Dr. Wittgrove: My two older children are on their own and I am very proud of them and their accomplishments. My oldest son worked in the program as our exercise coordinator for several years as he was finishing his Masters. He brought our program to a new level in that regard. He is now a high school counselor, which is his passion. My oldest daughter is a chemist. Since chemistry was a love forward-thinking at the time and ensured that we would know how to operate and operate with scopes.

If there is one thing I think I or we could have done differently, I think it would have been training in laparoscopic gastric bypass. There became too big of a push to offer it and I think some surgeons started operating before they were ready. I feel as though the actual didactic and hands-on training in laparoscopic gastric bypass was good, but that the credentialing perhaps should have been stronger earlier. My overall philosophy is more to rely on the goodness and right of the individual and to not want to impose more rules and oversight from central governing bodies; but with laparoscopic bariatric surgery, central oversight is needed and there should have been more of it earlier.

Looking back, how do you view your accomplishments?

Dr. Wittgrove: This is another question that makes me think about what I do and what I have done in a different light. I am a pretty simple guy. I love surgery and I love caring for the patients. I truly think bariatric surgery was made for me.

We often talk about it as the family practice of surgery. I like to think that the accomplishments that I have been associated with that have made a difference are:

• Practicing excellence in bariatric surgery before bariatric surgery was fashionable.

• Critically studying our procedure so that we can truly feel comfortable with predicting outcomes ranges.

• Of course, being the first in the world to do an operation is rather special. But when you couple it with how important that operation is, for the individual and for society, that accomplishment gives me great pride. Although I wish we could have done something different as far as laparoscopic training and credentialing are concerned, I am proud to have been such an active player during those times. It was important to expand the surgical base so that we could assist patients in access to care, and I think we did that rather well overall.

• During my residency, there were several things that happened that I can take credit for but I was blessed with many others who helped bring all those items to fruition. During that year, we conducted the ASBS Consensus to update the 1991 NIH, which has literally saved many bariatric surgeons from being forced out of the practice they love. We also started the Surgical Review Corporation. I’ve been told you are experienced in expert witness testimony.

What are some related insights regarding bariatric surgery?

Dr. Wittgrove: I have learned that bariatric surgery is high on plaintiff lawyers’ lists. It does seem that nearly any complication is at risk of a suit and that realistic informed consent is very important. Surgeons need to inform patients when they are doing their early cases and surgeons need to be honest about the complications they do have. It’s also important for all of us to realize complications do happen and that we shouldn’t throw stones. Unfortunately, there are a few surgeons who have made quite a good living testifying against fellow surgeons. We as a group need to look critically at testimony of some “professional” witnesses to be sure they are consistent and truthful.

What do you see for the future of bariatric surgery?

Dr. Wittgrove: We need to concentrate on being “metabolic surgeons.” Physiologically, that is what we do and I strongly agree with Dr. Walter Pories on that point. We need to establish the fact that we are the best, most effective treatment for Type 2 diabetes, and that, therefore, we need to be the first treatment of choice for patients with diabetes even if they are not morbidly obese. Certainly, there are endoluminal procedures in our future, and we should all maintain our proficiency with those skills.

Category: Interviews, Past Articles