An Interview With Kelvin Higa, MD, President of the American Society for Metabolic and Bariatric Surgery

This decade has proven to be a very dynamic and exciting time for bariatric surgery. The number of weight loss procedures has grown at an exponential rate and so, too, has membership in bariatric surgical societies. This past June, the largest bariatric society, the American Society for Bariatric Surgery (ASBS) convened in San Diego. In recognition of the profound metabolic effects of bariatric surgery, the ASBS members voted to change the name of their society to the American Society for Metabolic and Bariatric Surgery (ASMBS). The outgoing president, Philip Schauer, MD, announced the name change and also at the meeting passed the presidential baton to Kelvin Higa, MD. Dr. Higa, a general surgeon from Fresno, California, has been a pioneer of minimally invasive bariatric surgery.

Medscape's Timothy Kuwada, MD, recently had the opportunity to talk with Dr. Higa about the ASMBS, the future of bariatric surgery, and the controversial issues surrounding "Center of Excellence" designations. (The interview has been edited for clarity and grammar.)

Medscape: You are half way through your term as president of the ASMBS. What has been accomplished and what would you like to see accomplished?

Kelvin Higa, MD: I cannot take credit for anything. It's kind of like walking into the cockpit of a 747 in mid air and taking credit for the flight, when really, it goes to all of the people who have come before you. Most of the things that have been materializing over the past 6 months have been the result of planning over the last few years. One major change has been the ability to highlight the positive impact of bariatric surgery rather than just the complications. The recent publicity of several landmark bariatric articles was received well by the press. Our members have been active in communicating to the press and the public the story of obesity, the multifaceted disease that it is, and the benefits of a quality bariatric surgical program.

In terms of the future, I think the success and broad acceptance of bariatric surgery can lead to the same sort of exploitation seen in other surgical specialties. Experience has taught us that unregulated growth and emergence of new technologies can lead to poor outcomes. Centers advocating merely a procedure -- without the necessary program -- capitalize on the "quick-fix" mentality and ultimately will not have the long-term success of established multidisciplinary programs. This is one of the reasons the ASMBS started the Centers of Excellence (COE) program.

Medscape: As the new president of the ASMBS, have there been surprises or have you gained any new insights or perspectives into the Society?

Dr. Higa: There were no real surprises. I have served on the executive council for a number of years and the society is a close knit group. There are things going on that everyone does not know about. I was surprised to be nominated because so many others are more deserving of this honor.

Medscape: What was the impetus for changing the name of the ASBS to the ASMBS?

Dr. Higa: The society has been considering a name change for many years, but back then we were not ready [to change the name]. In the past, we tended to think of bariatric surgery as pure anatomic manipulation and less was known of the metabolic effects of surgery. But there has been a gradual appreciation that surgery can have a metabolic effect [on ghrelin and diabetes] and that the mechanisms for weight loss go beyond simply reducing gastric volume. Our name [ASBS] did not really describe what we do. One thing we did not want to do was to forget our heritage. However, ultimately, it was the icons of the past who helped support the name change.

Medscape: Does the ASMBS have any specific initiatives to increase patient access to bariatric surgery?

Dr. Higa: Patient access is a major priority of the ASMBS. Bariatric surgery not only reverses many obesity-related comorbidities, but it actually is also a powerful therapy that can prevent disease. In addition the economic benefits are well known. Unlike many other diseases that have multiple therapeutic options, surgery is the only known effective treatment for morbid obesity. Yet, we continue to have to justify our rationale for our interventions. Patients are desiring -- and sometimes demanding -- surgery, but because of the barriers created by insurance companies, they have limited access to life-saving therapies.

Unfortunately, the insurance carriers will continue to limit the care of the obese as long as they can get away with it. Currently, few political action groups are standing up and saying "this is wrong...we need to cover obesity treatment (medical and surgical)." Even the NIH [National Institutes of Health] spends very little on obesity research despite the magnitude of obesity in our country.

Medscape: The ASMBS recently announced that all COEs must participate in the BOLD database. Do you think this is too onerous on the average practice?

Dr. Higa: It is an expensive endeavor, but we need databases such as BOLD [Bariatric Outcomes Longitudinal Database] to gather the data and answer some of the unknown questions in bariatric surgery. We need to establish the benchmarks by which we should be held accountable.

Medscape: The BOLD database seems to have 2 primary objectives. One is to determine a surgeon's and/or center's outcomes (mortality, morbidity, follow-up, and weight loss). The second is more research oriented and is designed to tease out long-term outcomes of comorbidities, similar to a multicenter trial. It is this second component that increases the complexity and time required to enter data into BOLD. It also places an added burden of consent and internal review board (IRB) approval on the surgeon. Is it fair to require surgeons to participate in research as part of the criteria to be a COE?

Dr. Higa: Sometimes sacrifices have to be made. This is something that has been heatedly debated among the leadership of the SRC [Surgical Review Corporation] and ASMBS: "Is it right to require surgeons to participate in research in order to be a COE?" But I am asking the members of the ASMBS to make a leap of faith. To believe that each individual's efforts will benefit not only themselves, but also the specialty and ultimately our patients as well. It is admittedly a hard sell, but one I believe in. I think everyone out there is better off today than they were 5 years ago. Much of the credit goes to our increased legitimacy through our COE programs and the concept of quality care and improved outcomes.

Medscape: Do you think the volume requirements to become a COE are fair to young surgeons?

Dr. Higa: We are working on ways to make it more equitable for young surgeons who have completed bariatric fellowships. Hopefully in the near future they will be able to count their fellowship cases towards the criteria. We have also begun to appreciate the importance of the portability of a surgeon's COE status. It is extremely important that surgeons have the right and option to move their practice. If a surgeon cannot take their COE status to a new hospital, it may have the untoward effect of anchoring a surgeon to a particular hospital system.

Medscape: Have you seen a downturn in the applications for COE?

Dr. Higa: Yes we have. Surgeons want to know what value they are getting for the extra time, effort, and cost of the program and BOLD. "How is this going to benefit me as an individual?" Those are difficult questions, but these efforts have produced inroads into increasing insurance coverage for patients, which has benefited everyone. We have gained the respect of payors because we have been self-critical. What other specialty has formed its own organization to look back on itself and tell you whether you are excellent or not? What other specialty has stifled its own growth in the name of quality?

Medscape: What advice would you have for an established general surgeon who wants to start doing bariatrics?

Dr. Higa: Either join a group that is doing bariatrics and learn from them or do a fellowship.

Medscape: What are your thoughts on natural orifice transluminal endoscopic surgery (NOTES)?

Dr. Higa: I am somewhat skeptical, just like the last generation of surgeons who were skeptical of laparoscopy. Is avoiding an incision really that important, and does it justify a NOTES procedure? It seems like the laws of physics currently limit the applicability of NOTES. Robotics may allow us to overcome some of the physical constraints. But overall I am optimistic that NOTES may someday have a role. It is not something that I am going to see in my career, but it is something that may lead to interesting and derivative operations and add a new dimension to surgery.

Medscape: What are the major challenges to the future of bariatrics?

Dr. Higa: First we need to continue to improve access to care for all patients. Secondly, the trend of falling reimbursements poses a threat to the supply of surgeons. It is going to be difficult to attract surgeons to bariatrics. Who is going to want to be trained in a specialty where you can't make a living?

The other challenge is the evolution of our specialty. What we practice today is not what we will be doing in 5 to 10 years. We need to determine what new procedures are appropriate and safe and how to deal with weight gain recidivism.

Medscape: How did you get involved with bariatrics?

Dr. Higa: I had no bariatric training in my residency. Therefore, I thought, "What a stupid way of treating a medical problem. Why would you do surgery for a weight problem?" After joining a busy private practice in Fresno, the senior partner, Dennis Flora introduced me to the practical aspects of bariatric surgery: first the VBG [vertical banded gastroplasty], then the Roux-en-Y gastric bypass. Although technically intriguing, it wasn't until I was asked to advise a local HMO that [I was] led to a literature review and a better understanding of this specialty. I performed open gastric bypass procedures on a limited basis, as an adjunct to my general/vascular practice, never intending to make this a major focus. However, the results and success stories of my patients were intoxicating. We focused on the laparoscopic approach in 1998, 5 years after [it was] first described by Alan Wittgrove. The rest is history.

Medscape: What is your favorite bariatric procedure?

Dr. Higa: I am drawn to the technically challenging operations. Currently, I am concentrating on finding a safe laparoscopic approach to all patients, especially revision procedures. However, I still ask myself halfway through a revision operation: why?

Medscape: How about your favorite general surgery operations?

Dr. Higa: I still have a warm place in my heart for Whipple's. The combination of complex foregut physiology and vascular issues is always a challenge.

Medscape: What do you like to do outside the hospital?

Dr. Higa: I don't like to do anything [laughs]. In my spare time, I really do think a lot about surgery and how to make things a little bit better, a little more efficient. It's not that it consumes my life, but I always strive to improve my technical skills every day, to be more efficient, and to employ systems analysis and approach to finding solutions.

I have 4 kids, and with 2 months of traveling a year, life is pretty full right now. I do enjoy watching "Star Trek" reruns.

Medscape: So are you a Trekkie?

Dr. Higa: It's nice to be optimistic about the future. I like to think that technology will help to make the practice of medicine more humanistic and personal rather than isolated and sterile. I like Gene Roddenberry's idea of the future much better than HG Wells'.