Coffee time with Professor Natan Zundel

Bariatric News was delighted to speak with Professor Natan Zundel, President of IFSO and one of the pioneers of laparoscopic bariatric surgery in America. We discussed his career, his influences and the challenges facing bariatric surgery…

Did you always want to enter medicine?

I was only 15 when I finished high school and applied to university. My father was very strict and he asked me whether I wanted to study or whether I wanted to work. I said I wanted to study and he asked me what I wanted to study at university. I replied that I wanted to study art or philosophy. He looked at me with an angry expression and said: “In this family you either work or study one of four professions – law, medicine, engineering or economics.”

I did some research and law seemed a lot of hard work, engineering and economics were mostly mathematics, so only medicine really appealed to me.

How did you enter surgery and why did you decide to specialise in bariatric surgery?

When I started medicine I did not like it much, there was too much biology, biochemistry and anatomy. Then I started learning about general medicine and non-communicable diseases and surgery. Surgery reminded me of art because of structures of the body and how procedures had to be performed in certain steps, but you still can have your “own inprint”.

When I finished my surgical training, I traveled to England to study liver, kidney and pancreatic transplantation. On my return to Colombia, there were only two or three surgeons in the whole country performing these transplantation procedures and it was quite difficult to make a living. So my professor said to me I should do gallbladder surgery to earn a living – at the time this was still open surgery.

Natan Zundel

In 1990/91, laparoscopic surgery began to be adopted in Colombia and my centre was one of the first to perform the procedures. So over the next few years, I was the first surgeons in the country to perform a laparoscopic hiatal hernia repair, Heller miotomy, laparoscopic splenectomy and so on.

In 1995, I heard that a surgeon was coming to Colombia to perform two laparoscopic bariatric gastric banding cases. I had never heard of bariatric surgery being performed in Colombia. I was intrigued, so I went to see the procedures being performed and I was amazed at how simple the procedure was. Although I knew that there would be only a smaller number of cases that would be performed in Colombia, I wanted to learn the procedure.

So I attended the training course taught by Dr Favretti and in 1996 I convinced the hospital that we should perform the first two cases for free. Since then, I have performed about 10,000 procedures including more than 3800 laparoscopic gastric bands, over 3,000 sleeve gastrectomies and over 1,000 gastric bypass operations. I now spend half of my time doing revisions

Who have been your greatest influences and why?

During my residency, I had two important influences. The first was Professor Alvaro Caro who was my Chair during my four years. He wanted me to go to the US to continue my studying. At the time, I was tired of studying. I had done five years of medical school, a year of internship and a year of social service, plus four of residency. So, he kindly arranged a job for me with Professor Jose Felix Patiño, Honorary Fellow of the American College of Surgery. Professor Patiño told me that I had the skills to become a very good and very successful surgeon, but that I should save myself eight years of work to arrive to at that position and go overseas to look for something more specific, some form of sub-speciality So after some deliberation, I went to England and studied transplantation In Oxford at the John Radcliffe Hospital and in Birmingham at the Queen Elizabeth Hospital. Without these two remarkable teachers, I would never have had the opportunities I have had in life.

Is there any particular experience that has taught you a valuable lesson?

Over the years I have done a lot of training and proctoring and I really enjoy teaching and educating young surgeons about laparoscopic and bariatric surgery.  Sometimes they are not so keen to learn or they think they know things already, but it very rewarding when you share your experience with young professionals. I really enjoy watching them perform surgery and sometimes you see that they have listened to you, sometimes not.

I have taught people in Colombia, throughout South and Central America, in the Middle East, Europe, Canada and in the United States. Teaching is very challenging, but also equally rewarding. There are two phrases that I always tell my fellows and residents: “If it was easy, anybody can do it, so they do not need you,” and, “In order to enjoy life, you need to suffer.”

But I also learned something from all of them. That is a valuable lesson too. You can learn something from anybody.

What do you think of the current procedures for bariatric surgery, do you have a preferred procedure?

I would say that a procedure is something that is very individual to the patient. I am always quite critical if a surgeon only performs one procedure, because otherwise they will not know what is best for the patient. We know that all procedures fail at some point, but the outcome will be even worse if a surgeon performs the same procedure on every patient.

Also, more important, when you are giving a lecture in front of your peers, you need to be very careful of what you say, because young surgeons will believe everything you say. They will then return to their centres and tell everyone that ‘sleeve is the best procedure for diabetes’, or, ‘a bypass is a good procedure for a 15-year-old child, and so on. But this is not the case, so any message a surgeon gives on a podium or in a lecture or operation theatre must be measured and should be supported by the data, by evidence and also through experience.

What do you think of the new technologies that have entered the bariatric marketplace?

The current bariatric and metabolic procedures we have do not solve the underlying issues in every case and it does not matter how aggressive the procedure is, there will be a certain percentage of patients who do not have a successful or satisfactory outcome. This is understandable as obesity is a chronic disease. Yes, we can help patients achieve diabetes remission, but I think sometimes our message is wrong.

Perhaps it is because as surgeons, we are used to ‘curing’ a disease because we remove the gall bladder or the appendix. But when it is physiological, like reflux, we cannot cure everybody. Yes, we help a lot of people, but we don’t cure everyone. So the message we need to explain to patients is that if you have a balloon we can help you for 12 months, an endoscopic gastroplasty, one and a half to 2 years, a band maybe three to five years, a sleeve maybe ten years, a bypass maybe 15 years and so on. If the indications were correct at the beginning of treatment.

This is why I am open to different procedures and technologies because if we can find something that is very safe for the patients, cheap and effective, then I would welcome its introduction. I think that these new procedures should be taught across a multi-disciplinary platform with lots of education and evidence to support their use. I believe that some of these technologies are very good, the results are very encouraging, but that they are sometimes applied for the wrong indication.

Our role as leaders of bariatric and metabolic surgery is to closely examine all the data and scientifically scrutinise the evidence. We can then give our independent opinion – through a position statement on behalf of the society.

Such statements should explain how the procedure should be performed, when the procedure should be performed, to whom (candidate) and who should perform the procedure – always taking into account the multidisciplinary aspects of bariatric and metabolic surgery.

Some of the new technologies may work well in preventing obese patients or with a low BMI becoming morbidly obese. In the US, there are more than 40 million people who are obese, if you can prevent them from becoming morbidly obese – you have done a good job. Now, some of my surgical colleagues may not like what I am saying, but there are enough morbidly obese patients to keep us busy for the rest of our lives.

If we do not start finding solutions as a specialty in preventing obese patients becoming morbidly obese, other specialties such as gastroenterologists, endoscopic surgeons, endocrinologists, diabetologists etc, will find a solution. So as surgeons we need to be part of that prevention.

Finally, when you have time away from surgery, how do you relax?

I try to read as many books as possible, particularly history books, philosophy and I enjoy reading spy novels so I can embed myself in the story. I used to read one book a day but I do not have the time to do this now, but I still read two books a week. I also love watching sports, I cannot play many anymore, but I am from Colombia so of course I love soccer, but I also love watching American Football. I like to go to the theatre, listening to music and watching movies. I have many things to keep to entertained in my spare time.

I do not see my children as much as I would like, as they are all studying away from home. My eldest is studying neuroscience, my son is finishing college and wants to become a lawyer, and my youngest is in love with sharks, so she is now studying Marine Biology. My biggest regret is that I did not spend a lot of time with my children when they were younger, as I was always working. Maybe when I retire I can spend more time with them – if they remember who I am and they still want to spend time with me!