When's the Last Time You Did an Open?

Published in December 2013 Issue             

The Laparoscopic Revolution in
Bariatric Surgery 20 Years Later

Fifty-five-year-old homemaker June Tronier from Reno, NV is famous and doesn't even know it. She was the first patient in history to have a laparoscopic Roux-en-Y gastric bypass (RYGB) 20 years ago this past October. “I was just thinking about wanting to be skinny," June recalled. "I was young and I never really considered the potential consequences. But looking back, I’m very proud to have been a part of that new procedure.”

That new procedure, that surgery, and the thousands that followed ushered in a new era of bariatric surgery, which not only led to lower complication rates, shorter hospital stays, reduced recovery time and fewer hospital readmissions, but to greater acceptance of bariatric surgery as one of the safest and most effective treatments for obesity and metabolic diseases.

Today more than 90 percent of bariatric procedures are minimally invasive and the data shows these operations have become as safe as or safer than gallbladder and hip replacement surgery, two of the most common surgeries performed in the United States.

Alan Wittgrove, MD, FACS, FASMBS, past-president of the American Society for Metabolic and Bariatric Surgery, was the primary bariatric surgeon who performed that operation, which remains one of the most-performed procedures in bariatric surgery. However, it did take some time to catch on.

"When we did the first one, it was low key, under the radar," Dr. Wittgrove said. "But we knew it was the start of something. We did a second and then a third, and so on. Word started to spread. It was kind of a ripple effect. But, it really wasn't until we presented our first five cases at the ASBS meeting in June and published our data in Obesity Surgery in November 1994, that people really started to pay attention to what we were doing."

And people did pay attention -- both those excited about learning and doing this new procedure and those cautious and skeptical about its promise.

"I remember the first presentation at the ASBS meeting by Alan Wittgrove. I am embarrassed to say that I was a doubting Thomas," said Scott Shikora, MD, Director of the Center for Metabolic Health and Bariatric Surgery at Brigham and Women's Hospital in Boston.

Dr. Shikora, who performed the first successful laparoscopic gastric bypass in New England in 1998, feels differently today. "The laparoscopic gastric bypass may be the single most important innovation to bariatric surgery since its inception. It revolutionized the field by making the surgery safer and more acceptable to patients, their families and their PCPs. I think that Alan Wittgrove and Wes Clark (Wittgrove's partner at the time) showed great courage to develop the procedure and present their results. The impact of their work cannot be under appreciated." 

The first five laparoscopic gastric bypass cases performed between October 1993 and January 1994 were described in the journal Obesity Surgery in November 1994. Patients had body mass indices between 35 and 40. The authors reported that "all patients underwent uncomplicated procedures" and all recovered "uneventfully and were discharged by the second post-operative day." Procedure duration went from 7.5 hours to 3 hours "as experience accumulated." After three months, patients had between 42 and 67 percent excess weight loss. The study concluded that the "application of the minimally invasive technique of laparoscopic gastric bypass offers the affected patient a new option to achieve highly beneficial therapy with optimally reduced morbidity and disability."

There would be other publications by Drs. Wittgrove and Clark reporting on their outcomes. In 1996, they reported on 27 cases with 18-month follow-up and 75 patients with 30-month follow-up. In 2000, they published data on 500 patients with up to five years of follow-up, reporting average excess weight loss of about 80 percent by the first year and more than 95 percent of the significant pre-operative co-morbidities under control. Patient outcomes continued to be favorable over the five-year period. The authors concluded that "the operation has an adequate track record to show effectiveness, and training programs should be established to maximize safety."

"It was extremely important for us to document our outcomes. We needed to be data driven. We needed a numerator and denominator for context. If you had one complication back then, it was ruthless," Dr. Wittgrove said. "Even before the laparoscopic gastric bypass, the scrutiny on bariatric surgery was brutal. Bariatric surgery was held to an unfair standard. It was considered snake oil and discrimination played a role in the care and treatment of people with obesity among doctors and even other surgeons. Many would say it still plays a role."

June's older sister, Peggy Lee, had a successful open gastric bypass in 1983 and she says that at that time, "the shame of having the procedure was horrendous" and that the only person she told about it was her mother. By the time June had her surgery 10 years later, many of the negative perceptions of bariatric surgery had not changed.  

Why Go Laparoscopic?

According to Dr. Wittgrove, he was led to the laparoscopic gastric bypass in 1993 by a desire to reduce what was then one of the biggest complications of the open gastric bypass -- abdominal wall hernias. He had gone to Belgium, where he learned the laparoscopic Nissen fundoplication from Dr. Bernard Dallemagne, the surgeon who pioneered that procedure in 1991. It was there that it occurred to Dr. Wittgrove that the laparoscopic technique could be applied to the gastric bypass if he could only get the right instrumentation. He wrote in the Obesity Journal, "The key piece to the puzzle was the development of the ENDOPATH Stealth endoscopic/conventional circular stapler, 21mm, by Ethicon Endo-Surgery." When that stapler was approved by the FDA, Dr. Wittgrove already had a patient -- 35-year-old June Tronier -- waiting to get
the operation.

Dr. Wittgrove says he was excited about doing the operation, but not particularly nervous. "I thought if we had any problems, we would go open," he said.

As we know now, there was no need to go open. The procedure went as planned though it took several hours longer than the one to two hours it now takes to perform a laparoscopic gastric bypass. At the three month mark, June, who stood at 5 feet, 5 inches tall and weighed over 200 pounds, had lost 67 percent of her excess weight. Today, 20 years later, she weighs 60 pounds less than she did then and is in good health. She says she "still has to work to keep the weight off and that it wasn't some magic pill."

But while no magic pill, the laparoscopic gastric bypass was indeed an inspiration to some of the biggest names in bariatric surgery including Dr. Shikora, Kelvin Higa, MD and Philip Schauer, MD.

"It was a real game changer. It excited and inspired me and I wanted to be a part of it," said Dr. Schauer, who has performed more than 4,000 operations for severe obesity and is director of the Cleveland Clinic Bariatric and Metabolic Institute. "I knew the laparoscopic technique would make a significant difference for patients, and it has."

ASMBS Past-President Dr. Higa, who presented Dr. Wittgrove with the ASMBS Foundation's 2013 Outstanding Achievement Award during ObesityWeek, said that the first laparoscopic gastric bypass was "an innovation that set the tone for all minimally invasive surgery."

While many were inspired by what Dr. Wittgrove has accomplished, Wittgrove himself credits bariatric surgeon Boyd E. Terry, MD, for inspiring him to go into bariatric surgery when he was in medical school. He was moved by the way Dr. Terry took care of
his patients.

"He really wanted to help these people. He sometimes would spend a whole day with a single patient. I would watch this and think nobody wants severe obesity, nobody would want to live this way. Dr. Terry had so much empathy and would do everything he possibly could to help. That's the kind of surgeon I wanted to be," Dr. Wittgrove said.

After 9,000 bariatric operations and counting, Dr. Wittgrove remains as committed today to bariatric surgery and treating the disease of obesity as he did on that historic day 20 years ago. For him, there is still so much more work to do, so much weight discrimination to fight, so many diabetics to cure and so many more patients to help.