An Interview With WLS Pioneer Dr. Milton Owens
October 11, 2013Dr. Milton Owens recently hosted an insightful break-out session at the ObesityHelp National Conference in Anaheim, CA. He has been a long-time supporter of our community and the OH team was thrilled to have the opportunity to interview him one-on- one.
Making A Difference: Featuring WLS Pioneer Dr. Milton Owens
OH: (Tammy) Hello Dr. Owens. Thank you for taking the time to speak with me today. I know you are a pioneer in the field of bariatric surgery and that you have since performed over 8,000 weight loss surgeries. Can you share a little about bit about your history in the bariatric community?
Dr. Owens: Well yes. I’ve done a very large number of them. The majority of them are gastric bypasses because I started with them back then. Though I did vertical ring gastroplasties, I became sort of dissatisfied with the results. Back then Dr. Ed Mason (the father of obesity surgery from the University of Iowa and founder of the American Society for Bariatric Surgery) had tried gastric bypass and had one or two complications. He felt the surgery was too dangerous, so he was a strong advocate for vertical ring gastroplasty. I spent some time with him in about 1978, but thought that there was a better way to go. The problem was that patients did a lot of vomiting. They either switched their diets to high calorie soft diets, or the ring may not have been very tight and they simply didn’t lose much weight. We didn’t have an adjustable ring or adjustable band like we use now to fix the size.
I had a friend in Salt Lake City named Dave Miller. Dr. Miller had done quite a few gastric bypasses and he had really impressive results. His patients were doing well afterwards without any vomiting and they continued to lose weight. I spent some time with Dave Miller learning how to do gastric bypass. I was astounded at how much better an operation it was than vertical ring gastroplasty. Over the next ten years that’s just about all I did. Most of the other surgeons continued doing vertical ring gastroplasties but over time they all switched to the bypass. In about 1997, there was a big breakthrough to laparoscopic surgery. Almost simultaneously, Dr. Kelvin Higa in Fresno, and Dr. Allen Wittgrove and his partner, Dr. Wes Clark in San Diego started doing the laparoscopic gastric bypass. I realized that if I was going to survive as a bariatric surgeon, I had to learn to do laparoscopic gastric bypasses and keep up with those high-powered guys.
At that time, there were no training courses or fellowships available as there are now, and neither Dr. Higa nor Dr. Wittgrove wanted to teach anyone else. Dr. Higa did let me watch, as did Dr. Ken Champion when he started doing them shortly thereafter. So I made an arrangement with Ethicon and I went to their research building at USC where I could use their laboratories. I’d go up there two or three times per week for a couple of months. I spent so much time there that they got suspicious that I was doing research of some kind, but I was able to work on all kinds of ways to do laparoscopic gastric bypasses. After a while, I had it figured it out. I started doing laparoscopic gastric bypasses on my patients and subsequently modified the technique. It was clear that laparoscopic surgery really revolutionized gastric bypass because of the fact that it’s so much easier on patients. It turns out that the previously used large incisions were much of the cause of the trauma and stress patients experienced from the operation. The laparoscopic approach has been quite revolutionary for that reason. Even quite complex revision surgeries can now done this way and patients feel better sooner.
OH: You invented a new technique called the inverted corner gastric sleeve. Can you explain that procedure to our readers and explain what the benefits are?
Dr. Owens: As a clinician, if I’m going to make a contribution to our patients, I have to focus on improvements through surgery, rather than in a lab where I can study chemistry or operate on rats for instance. The gastric sleeve has been widely recognized as an impressive new addition to surgical options for weight loss. It’s taken off like wildfire across the county. The Achilles heel of it though, is that if a leak occurs, it tends to occur up where the wall of the stomach, by the esophagus, is rather thin. The closer you get to the esophagus, the thinner it gets. If a leak occurs there, it’s thin and narrow, which causes a back pressure, all of which make it very hard to get leaks to close. Leaks have been a real concern with the sleeve; not common, but when they occur they’re very difficult to manage, and in a rare case could result in mortality. Heart burn has been another problem of Sleeve surgery for many post-op patients. The surgical technique I developed diminishes the likeliness of a leak and prevents heartburn as well. By finishing the staple line a little way back from the esophagus, we create a kind of a corner on the sleeve. We turned that corner inside and inverted it. This doubles the thickness of the wall of the stomach at its thinnest part and creates a little valve that prevents, or helps prevent acid from going back into the esophagus and causing heartburn. We’ve done maybe a hundred of them now. It really does seem to work. I wrote a paper on it that’s been published in the ASMBS Journal. Another thing that I’m now working on that I believe will be a contribution to patients’ care, is an new operation to improve weight loss for those patients who regain after gastric bypass. The thinking now is that both the gastric bypass and the gastric sleeve cause the body to sort of reset your way to a lower weight as normal. It makes your brain and your body decide “I shouldn’t weigh 354 lbs, I ought to weigh 230 lbs instead.” There are some patients who unfortunately find that this set point can come back up. We can put a lap-band over it, but that only gives us the mechanical benefit of making the stomach capacity smaller again. What a ‘band over bypass’ cannot offer is a change in the physiology that controls hunger. Well what we’ve done is we’ve looked hard at the literature and there seems to be pretty good evidence that if you remove the Ghrelin inducing portion of the stomach that you can reset the physiologic changes of the gastric bypass and patients will lose weight again. We are starting research where some of our gastric bypass patients who have regained weight will have that portion of the stomach removed, and we’ll compare them to patients who don’t have that portion removed to see if we can demonstrate if that produces renewed weight loss.
OH: That sounds very interesting and exciting . You’ve published a research page on the simpler method of predicting weight loss in the first year after gastric bypass. In your research for predicting the target rate during the first year, can you explain to the readers what factors you considered with race, age, gender, and all of that. And maybe summarize for the readers what the key points are on your research that they could appreciate.
Dr. Owens: We published an article in the Journal of Obesity Surgery and also a poster made for the latest ASMBS meeting. We tried to figure out a simple way to tell patients how much weight they’re going to lose in a given period of time. Patients often ask 3-4 months post-op how they are doing compared to other patients. Usually you have a good sense of it from seeing lots of people without having any kind of numbers to rely on. We took ~1500 patients who had gastric bypasses and we looked at their weight loss over time through the first two years. We were able to construct a curve that allowed to us to tell them that you’ll weigh this much in six months, and so on. We noticed as we were analyzing the data that at one year hardly anything else mattered…just about everybody had lost 60% of their original weight. So we took all of the patients again and we sort of normalized their weight for that. We looked at everybody just to see how that panned out and that it was in fact true. So you could say just about anybody who’s had a sleeve or a bypass, not a band, would weigh about 60% of what you do now in a year. And that’s a simple and useful formula although we know that there are a lot of things that influence how much weight people lose. For instance older people don’t lose as much as younger people. Woman not quite as much as men. We know that African Americans don’t lose as much as Caucasians. All of those factors really don’t seem to matter very much, if we analyze the importance of all of those factors and take them together they only influence outcome as compared to original weight by one or two percent. What really drives weight loss is how much you weighed at the beginning and the time after weight loss. What you get out of it is a kind of handy way of telling patients how much they will weigh in a year. And that’s true whether you’ve had a bypass or a sleeve, short, tall, man or woman.
OH: You answered another one of my questions too, thank you. Are your findings based on your own personal patients or are they of the co-authors of the study as well.
Dr. Owens: Well it was my patients but there were co-authors. I had a very bright medical student named John Sespeniak who helped me analyze the data and we had a statistician from San Diego, so there were other people involved. They were all my patients, but I think that nevertheless it would be true of anybody else's patients. But you’re right…the one factor we didn’t analyze was what kind of difference would an individual surgeon make. And we assume there isn’t’ much difference between surgeons. At least as far as that goes.
OH: Do you see any standardization in the field of evolution towards personalized medicine where clinical pathways are customized based on multiple individual attributes.
Dr. Owens: What your question is sort of coming out of is the increasing amount of data that says that people of a certain genetic characteristic with certain kinds of genes, for instance, are much more likely to crave sweet foods or more likely more resistant to weight loss. And yes, there is genetic information that is coming down. Pretty soon there will be bio markers that will allow us to identify people and identify differences in people and in the way they respond, for instance, to exercise. We know that there are people for instance that exercise doesn’t help. And yet for most people, it does. We talk to patients who swear that there only taking in five or six hundred calories a day, vegetables and meat, and they’re not losing any weight. The tendency has been to suspect they’re not totally telling you the truth. The reality is that they may be coming pretty close, but that people are just different. We really don’t know the differences. Simple answers like calories in versus calories out , low carbs , high proteins, exercise, all of those things are right in the broad stance, but may only going to be right for some people, some of the time. As time goes on, we will probably identify other things, besides diet and exercise, that are going to be quite influential on the way that people lose weight. For instance, one of the interesting results of gastric bypass is a change in the bacterial population of the intestine. Certain bacteria predominate in thin people and another type in seriously overweight individuals. Gastric bypass changes the population of bacteria from that of overweight to that of thin people. What makes this even better is that the bacteria seem to influence the resting caloric expenditure in a person as well as how many calories get extracted from food headed down the GI tract. It is as yet untested but the strong suggestion is that the right probiotic could produce weight loss. Biology is evolving so fast and it’s clear that our concepts have been quite simple. The concepts of the future are not going to be that simple.
OH: I want to talk a little bit about the weight loss surgery timeline and the history. I remember about 15 years ago the industry, as you will remember, was undergoing extreme pressure and discrimination. Do you think there was a silver lining that resulted in helping accelerate the push of weight loss surgery as an art to a science?
Dr. Owens: When we first started doing weight loss surgery, our fellow physicians thought of it as excessive over-treatment for people who probably could be managed just as well with diets and exercise. It was simply the fact that we were making so many people really, really happy that kept us going at it. The silver lining you brought up is that the critical attitude of our peers forced us to become very good at what we did ; it forced us to make surgery very safe. Weight loss surgery now is done extremely safely compared to other operations. Mortality risks are now like one in a thousand. That’s extremely good when you figure that gall bladder mortality risk is like one in two hundred. We’ve gotten very good at it and it’s lovely because we’re also providing a surgical solution that not only makes patients better than they were before they got sick, but better than they’ve ever been. Compare that to taking out your appendix for instance; at the end of the day you’re as good as you were before you got appendicitis. If I help you lose 150 lbs you’re better than you’ve ever been in your life.
OH: It seems like one of the consequences of the discrimination against bariatric surgery was that weight loss surgeons have been held to a higher standard. We have had the Surgical Review Corporation (SRC) where you have had to actually answer for this life saving procedure. For example the gall bladder surgery… if the gall bladder is taken out a surgeon doesn't have to answer as to why it was removed or justify the procedure to the extent weight loss surgeons have had to. How do you feel about that?
Dr. Owens: Well that’s true. The Surgical Review Corporation was created as an effort to gather data to improve the outcomes of bariatric surgery and demonstrate to the rest of the community that the outcomes were quite good. If we were doing gall bladders and so on, you’re right, we would not have had to make that kind of an effort because it was already an accepted procedure. Now with the popularity of weight loss surgery - the insurance companies are making us go through so many hoops to get approval for patients, that it’s increasingly clear they don’t want to pay for it anymore. I think there are too many people who need it and want it and insurance companies just don’t want the expense. It’s going to become a procedure that isn’t paid for by insurance. It’s already to a large extent that way.
OH: Do you see downsides to the SRC and is the SRC still relevant?
Dr. Owens: The SRC has been superseded now by the ASMBS and the data collection. I’m not even sure there’s a name for it now, but all of the data collection is now through the certification centers and ASMBS and that is going to be merged with data collection and probably oversight from the American College of Surgeons. So it’s gone an entirely different direction.
OH: Do you see any improvement with primary care physician's (PCP's) on board supporting weight loss surgery? I know that because of the “do no harm” oath... even if there was a 1% chance of a death primary care physicians would be hesitant to approve of a patient going through weight loss surgery years ago. Do you see improvement there now?
Dr. Owens: Well yes, there’s been data collected to show… for people who meet the usual criteria for surgery… that life expectancy and quality of life is increased with this surgery. Primary care physicians and orthopedic surgeons have come to recognize that the weight loss has benefited their patients a great deal and that it is safely available to their patients.
OH: How do you feel about your personal mentorship impact on junior surgeons and on bariatric surgery as a whole?
Dr. Owens: I’ve helped in the training of a number of younger surgeons in a non-standard sort of academic environment. It’s always been really overall pretty rewarding. The nice thing about trying to teach somebody something is that you can’t help but learn yourself and so I think every time you do that, hopefully they end up better off but I’m sure at least in my experience I’ve managed to become better off as well. You learn from the people you teach.
OH: I know that you promote responsible weight loss for seniors and I was reading about one of your patients. He had weight loss surgery so that his caregivers could tend to him better. Can you tell us a little bit more about weight loss surgeries for seniors and balancing the pros and cons of that? And what’s the oldest patient you’ve personally operated on?
Dr. Owens: I’ve operated on a number of people in their mid 70’s though I’m not sure who’s the oldest but I think what’s kind of interesting about operating on older people, of course, is the question about who should you operate on. Patients often ask that one way or another… “Do I meet the criteria?”. The criteria are only guidelines. The key to surgery and any kind of treatment is this…Is the treatment going to be safer than non-treatment? That’s the bottom line. Beyond that, even if its not safer, than say hip replacements or cosmetic surgery, if there’s a decided improvement in quality of life and the patient understands that they’re trading risk for quality of life, then that’s also okay. And that’s what you have to do with older people. You have to first of all decide is it safer for them to have surgery than not. Am I going to improve their diabetes and high blood pressure and so on enough to justify the risk of having an operation. You have to ask if they want to trade risk for the improvement of their quality of life. There’s some risk but what you may get is a better way of life. One of my patients in his 70’s, could barely bring himself into my office…his feeling was” I can’t go on like this at all. I don’t care about the risk I need to get out of this situation”. Like all stories in medicine it’s either a disaster or a miracle, this case being a miracle as he lost 150 lbs. He’s in great shape now, his whole life is improved. It’s really something to be a part of that.
OH: What about weight loss surgery on teens, what are your thoughts about that? And do you operate on teenagers?
Dr. Owens: Yes, I do. I use the same sort of guidelines but they’re sort of applied differently. In teens, instead of looking at increased risk from surgery as you look at it with older people, you instead find that they’re pretty hardy. The risk is lower, but the other side of this is that they have to live with the changes of surgery for much longer periods of time. You have to kind of bring that into the equation. Also with teens it’s important to have a feeling for understanding where the teen is mentally. Do they really understand what they’re getting into? The responsibilities of making use of the operation in such ways to not just squander the benefits. Teens don’t trust doctors very much or older people very much so its kind of hard to communicate with them. For a fragile time in life it’s nice to fit in and be better looking and more athletic. So there are some special social advantages to teenagers that comes from losing weight.
OH: What do you see about the future of weight loss surgery, upcoming procedures, anything excited about in the future of weight loss surgery? Do you think genetics come into play at all?
Dr. Owens: Well, the whole interplay of genes and environment that is moderated internally by chemical signals and nervous signals is already very complicated. And it’s going to get even more complicated because new things are being found out all the time. In terms of new approaches, I think trying to remove the Ghrelin, from a clinicians point of a view, is my best hope for contributing. By way of moderating it, by understanding the interaction of the patient and environment. A lot of this stuff will become clearer over the years.
OH: I was wondering, as I’ve been with ObesityHelp almost since it’s inception (1998), how would you say ObesityHelp has been relevant to the bariatric community as a whole and to your patients and your surgeons?
Dr. Owens: I think you’ve been wonderful advocates for obesity surgery for as long as I’ve known. I think you’ve become kind of a rallying point for over-weight people. A place where they can go and exchange information, they can get authoritative help. I think you’ve done a lot along those lines. Don’t you?
OH: Yes, I do. I feel proud to be part of the team. My mother was a bariatric nurse and ObesityHelp was her passion— Thank you so much for your time today Dr. Owens and thanks for all you do to support the Obesityhelp community and those fighting the disease of obesity.
Dr. Owens: Thank you.
Milton Owens, MD, FACS, FASMBS serves as the director and as a surgeon with the Coastal Center for Obesity. Read his full bio here.
