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Coffee time with...Michel Gagner
Did you always want to enter medicine?
When I applied for medicine, I also applied for chemical engineering and I was accepted. But at the last minute, I decided to go into medicine primarily because my dad was a gynaecologist so that influenced my decision. I am the eldest of four boys, but I am the only one who entered medicine.
Why did you decide to specialise in bariatric surgery?
I entered medicine at the age of 18 and graduated at 22 and very early on I realised I wanted to become a surgeon. When I did my surgical training, bariatric surgery at McGill University was part of the general surgery training programme. I was exposed to bariatric surgery by Dr Lloyd D MacLean, who later became President of the American College of Surgeons, and he undertook open bariatric surgery in a very scientific and controlled way, performed randomised studies and was supported by a great bariatric team. I was impressed by his methods and it certainly made an impression on me.
However, when I finished my training I wanted to become a hepato-biliary surgeon so I performed liver surgery in Paris with two of the foremost liver transplant surgeons at the time, Drs Henri Bismuth and Dominique Franco. After my time in Paris, I then moved to Boston for a year under the guidance of Dr John Braasch. This year saw the advent of laparoscopic cholecystectomy and I realised that despite all of my surgical training if the future was procedures such as laparoscopic cholecystectomy, then I was not prepared at all.
So before starting my job in Montreal, I went to Nashville, Tennessee, for one month to be a free assistant to Drs Eddie Joe Reddick and Doug Olsen. At the time, they were the pioneers of laparoscopic cholecystectomy in North America. When I returned to Montreal, I started to organise courses in laparoscopic cholecystectomy for Canadian surgeons. I established a research laboratory and began to look at other laparoscopic techniques such as hepatectomy, pancreatectomy, adrenalectomy and splenectomy. The first years of my early laparoscopic career were focused on hepatobiliary and solid organs, and I even explored endoscopic thyroidectomy in pigs.
Unfortunately at Montreal they did not have a bariatric surgery programme nor a history of bariatric surgery, and I was told by the Chief of Surgery that I could not perform bariatric surgery there.
It was when I arrived at the Cleveland Clinic in 1995, I really re-started to perform bariatric surgery and I established their first laparoscopic bariatric programme. At the time there was only really Drs Alan Wittgrove and Wesley Clark from San Diego who were really performing laparoscopic RYBG in the United States.
Who have been your greatest influences?
The great influences on my career have been Lloyd MacLean, Henri Bismuth, Dominique Franco and John Braasch.
What experience in your training/ career has taught you the most valuable lesson?
I think every day we learn from new experiences. One of the most important things for a surgeon is humility. Sometimes we perform surgery and you think all is going well and then complications occur. It is important to remember that we are all human and these things happen every day.
Another lesson is to persevere and be persistent. When I wanted to perform a laparoscopic bypass in Montreal, I was prevented from doing so by the Chief of General Surgery. We had already done all the necessary animal research, performed the procedure in pigs and published our findings. Unfortunately, the procedure was cancelled and I was very disappointed. Nevertheless, I continued my work at the Cleveland Clinic and re-doubled my efforts to establish a laparoscopic bariatric surgery programme. So I learnt that it is important to believe in yourself and be persistent. Just because you face hurdles and have setbacks does not mean you should stop.
Do you think you would face the same opposition today?
I think so. At the beginning, laparoscopic surgery faced a lot of resistance from the more conservative general surgeons, who believed the best procedure was an open procedure. Many surgeons at the time said laparoscopic surgery was a ‘gimmick’ or a ‘fad’, and we were heavily scrutinised by our more conservative colleagues. Some of the advocates of laparoscopic surgery were penalised and had their licence suspended or their hospital privileges removed. There were a lot of difficulties in the beginning.
When I started laparoscopic bariatric surgery at Cleveland Clinic I had to undergo the ten cases special review by a committee from the Department of Surgery. For me, persistence and belief was the key.
What have we learned over the last 15 years to prevent higher instances of anastomotic leaks and stapleline haemorrhages?
When we first started performing laparoscopic gastric bypass, we were using a generation of staplers that were not as good as today’s devices. At the time, the staplers were poorly designed and as first generation devices they were only 30mm long. They were also very limited in terms of staple height and ability to manoeuvre the stapler.
In the last 20-25 years, the industry has really responded to the challenge, and we have seen vast changes in the technology. So in the early days we had more leaks from gastric bypass and what we learned is not to rely on mechanical staplers but to add more sutures. I believe that as you become more experienced with bariatric surgery you tend to re-enforce more by adding more sutures, be very delicate, and respect the tissue and blood supply.
Are there any plans to update the laparoscopic sleeve gastrectomy consensus paper?
Yes, at the XIX IFSO World Congress in Montreal we will be hosting the 5th International Conference on Sleeve Gastrectomy and on the second day, Dr Raul Rosenthal will be hosting a consensus discussion. We are requesting that the experts in the discussions have performed more than a 1,000 sleeves. Our goal is to have 100 surgeons from all over the world so we can hopefully have a combined experience of 100,000 sleeves.
It has been nearly two years since the last consensus so I think it will be interesting to see what discussions emerge, whether it is about new data or new devices that are helping to achieve better outcomes. We especially want to know how these experts manage complications such as leaks and reflux.
We will be asking similar questions to those asked in 2012 and some new ones. The results will be shown at the end of the conference, and published in a peer-reviewed journal at the end of this year or early next year.
Do you think any of the new technologies may replace more tradition surgical procedures?
There have been a lot of start-up companies in the last few years but many of them seem to have a short lifespan. I think laparoscopic surgery whether it’s a bypass, duodenal switch or sleeve, is the most effective way to treat obesity and I don’t see anything that will change that in the next ten years. I think some of these new technologies might be used to decrease the risk from surgery for some of our patients in order to allow them to have surgery, in similar way the gastric balloon can be used.
I think one of the biggest challenges these companies face is the issue of cost and some of these devices are expensive at a time when cost needs to be reduced. I am sorry to say that for a lot of these innovations, although very interesting concepts and I always enjoy hearing about them, I do not see them making a breakthrough at this time.
What are the biggest challenges facing bariatric surgeons in Canada, and the world, over the next ten years?
Our biggest challenge is accessibility, to make bariatric surgery accessible to a much larger percentage of the population. Year after year obesity and diabetes keeps increasing and the number of patients put forward for surgery as a percentage is decreasing, so we are not having an impact on society.
I have always said that obesity and diabetes are the healthcare challenges of the 21st century and as a bariatric community, we must demonstrate that bariatric surgery is safe so it becomes part of main stream healthcare provision in battling obesity.
In the 20th century, we created hospitals for treating cancer, we created hospitals dedicated to coronary and pulmonary disease (TB), when both were seen as the challenges of the time. But we have not yet created hospitals dedicated to treating obesity and diabetes, and we need super hospitals that are dedicated to this problem so we can treat the huge number of patients needing treatment. I am not just talking about surgery; we are at the tip of the pyramid but at the bottom there are huge numbers of people who would benefit from improved medical care, improvements in lifestyle changes, dietary education and psychology. If we really want to make a difference we need hospitals everywhere dedicated to this.
It is an economic and political issue. As surgeons we know what needs to be done but the politicians are not listening. As surgeons, physicians and patients, we need to come together to lobby governments to make societal changes. It is our biggest challenge.
What are you current areas of research?
I am interested in trying to make surgery less and less invasive through laboratory and clinical research. I am also involved in refining procedures such as the single anastomosis duodenal switch, I think this procedure is likely to expand and could assist sleeve patients who have regained weight after their procedure. We are now at the stage in bariatric surgery where we recognise that each procedure has its failures. A single anastomosis duodenal switch offers one such solution, if we can find a solution to make it easier to perform and less problematic in terms of complications.
Finally, when you have time away from surgery, how do you relax?
As you know we live in Canada so half of the year its winter and since I was young I have enjoyed cross-country and downhill skiing. We do this as a family and we invite friends and although everyone has a different level of skiing, everyone enjoys it.
I also enjoy mountaineering with my Canadian friends. I started about 12 years ago and now every year we climb the Andes and regularly climb to over 6,000m. Over the years we have gone to Ecuador, Bolivia and Peru, and I hope our next climb will be in Argentina. I still enjoy playing squash and have done since I was introduced to the sport in Newcastle-upon-Tyne in the UK when I was a sixteen-year-old student … and I still beat my sons, although at my age I don’t think that is going to happen for much longer!
Would you like to make any additional comments regarding your career?
I first started in laparoscopic surgery in 1990 and nearly 25 years later I look back and think it has been a meteoric rise. From the beginning we were doing one or two procedures and now, I find it’s non-stop teaching courses, writing papers or presenting to colleagues around the world. I am very thankful for the opportunities and experiences laparoscopic surgery has provided for me and my family.
Laparoscopic surgery has provided me with some wonderful experiences for which I am very grateful. I am also thankful for the support of my wife of 30 years, France, and my three sons, Xavier, Guillaume and Maxime.