A Message from Dr. Mathias A.L. (MAL) Fobi
Mathias A.L. (MAL) Fobi, MD, FACS, FICS, FACN, FASMBS, is a senior staff surgeon at Cedars Sinai Medical Center in Los Angeles, California. He has served as the President of the American Society of Metabolic and Bariatric Surgery Foundation (ASMBS Foundation), the California Chapter of the ASMBS (CCASMBS), and the The International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO).
In the June 2016 issue of Bariatric Times, Dr. Henry Buchwald contributed the guest editorial message titled, “Metabolic, That’s All,” in which he discussed the origins of “bariatric surgery” and “metabolic surgery” terminology. This is an important topic that I have personally been thinking about for a while, and I propose the following terminology to describe what we do: Bariatric Metabolic Surgery.
Dr. Buchwald explained that the emphasis on the metabolic effects of bariatric surgery (i.e., management of type 2 diabetes mellitus [T2DM]) was good but not reasonable or realistic because it reversed the natural order of rank. “Bariatric surgery has, and always will be, a manifestation of the larger phylum of metabolic surgery,” he stated. While I agree with that statement, I have more to add on this topic.
In order to discuss the evolution of terminology surrounding our field, we must first examine its history. In 1954, Linner et al from the University of Minnesota introduced jejunoileal bypass (JIB) as the first effective procedure for weight loss. Through comparative studies, they found that sacrifice of the distal 50 percent of the small intestine produced a profound interference with fat absorption associated with loss of weight. Back then, we referred to these operations as “obesity surgery” or “weight loss surgery.”
Historically, our field and the individuals we treat have suffered from prejudice and bias stemming from the word “obesity.” While we have made progress in breaking from these prejudices, they still exist. (Dr. Still elaborates on obesity stigma and weight bias in last month’s editorial message.) George Bray came up with the term “morbid obesity” to distinguish the condition as something that could be treated and had a medical indication. Use of the word “morbid” described the known co-morbid conditions of obesity, such as type 2 diabetes mellitus (T2DM), hyperlipidemia, hypertension, obstructive sleep apnea (OSA), and others. In the 1950s and 1960s, we were operating on individuals who were morbidly obese or 200 percent their ideal weight based on the Metropolitan Life Height-Weight Tables.
By the 1970s, Drs. Edward Mason and Ito introduced the gastric bypass, which was less complicated and had less side effects then the JIB. In an effort to make it more acceptable, based on bias and prejudice toward the word “obesity,” use of the word “bariatric” was suggested during the Bariatric Surgery Colloquium in Iowa City, Iowa. (Note: the meeting wasn’t called the Obesity Colloquium.) “Bariatric” derives from the Greek words “baros” and “iatros.” Baros and barys translate to “weight” and “heavy” and “iatros” to “physician” and “healer.” From this meeting, the American Society for Bariatric Surgery (ASBS), now the American Society for Metabolic and Bariatric Surgery (ASMBS) was founded. I attended this meeting and can recall a lengthy discussion about what to call the society before agreeing to ASBS.
We performed more operations and started reporting more results with evidence-based data from prospective, retrospective, and comparative studies and documenting the comorbidities and amelioration of those comorbidities, it became apparent that we were treating more than just the weight. As early as 1983, I wrote an editorial in publication called Bariatric Surgery discussing the use of bariatric surgery to treat T2DM. More people started talking about the metabolic effects of bariatric surgery, and between 1987 and 1988, Buchwald and Varco introduced the idea of metabolic surgery in terms of describing bariatric surgery. At that time, it did not gain popularity.
The idea garnered more attention in 1995, after the publication by Pories et al in the Annals of Surgery titled, “Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus.” This article brought to light that bariatric surgery could be used to treat obesity and diabetes. It is important to remember, however that “bariatric surgery” was always treating diabetes and the other co-morbidities of obesity mentioned previously. In fact, many studies were conducted in order to determine which operation was the best treatment for known comorbidites. For instance, the Program on the Surgical Control of the Hyperlipidemias (POSCH) trials showed the best treatment for hyperlipidemia is the partial ileal bypass. Scopinaro et al demonstrated the beneficial effects of biliopancreatic diversion on T2DM.
The gastrointestinal tract’s role in obesity and T2DM began getting a lot of attention, and in 1999, the role of ghrelin became apparent. It also became apparent that the effects on diabetes occurred before the weight loss, illustrating the importance of bypassing the gastroduodenal axis. These findings came together and brought popularity to the particular mechanisms of bariatric surgery that ameliorated diabetes. Since then, we have heard the term “Diabetes Surgery,” particularly from Drs. Francesco Rubino, Philip Schauer, Ricardo Cohen, David Cummings, and Lee Kaplan through the launch of the Diabetes Surgery Summit (DSS) in Rome, Italy in March 2007.
In June 2007, The ASBS and The International Federation for the Surgery of Obesity (IFSO) added “Metabolic” to their names to reflect the mounting clinical evidence of the effectiveness of surgery on metabolic diseases, such as T2DM. While I agree with the inclusion of “metabolic” in our terminology, I think we should replace the following terms: “Bariatric Surgery,” “Metabolic Surgery,” “Bariatric and Metabolic Surgery,” or “Obesity Surgery” with the name I am proposing, which I believe to be the best term to describe what we do—“Bariatric Metabolic Surgery.” As Dr. Buchwald stated, bariatric surgery is a metabolic operation. I think that “bariatric,” however, should not be dropped, but rather used as an adjective because there are different types of metabolic surgeries that are not performed to induce weight loss. For instance, splenectomy for congenital hematologic disease is a hematologic metabolic operations, removal of ovaries and testicles for cancers is an oncologic metabolic operation, and jejuno-ileal bypass to treat hyperlipidemia is an intestinal metabolic operation.
I think bariatric metabolic surgery is an acceptable term because it encompasses all specialties involved in treating the various comorbid conditions of obesity—T2DM, PCOS, infertility, OSA, hypertension, hyperlipidemia. The National Obesity Summit on the Provision of Care for the Obese Patient hosted by the ASMBS and led by Dr. John Morton is an example of achieving this unity as it brings together representatives from more than 30 major health and medical organizations. However, I believe that we should consistently use the proposed term “bariatric metabolic surgery,” as it achieves many of the goals our field aimed for in the past: 1) eliminates using the term “obesity,” 2) covers all comorbid conditions, and 3) further connects the definition of “metabolic surgery” (operating on a normal organ to improve health) to its effects on weight loss and weight maintenance.
Mathias A.L. (MAL) Fobi, MD, FACS, FICS, FACN, FASMBS
1. Buchwald H. Metabolic, That’s All. Bariatric Times. 2016;13(6): 3-4.
2. Kremen AJ, Linner JH, Nelson CH. An experimental evaluation of the nutritional importance of proximal and distal small intestine. Ann Surg. 1954 Sep;140(3):439–448.)
3. Buchwald H, Varco RL: Editors, Metabolic Surgery; Grune and Stratton, Publ, New York; 1978.
4. W J Pories, M S Swanson, K G MacDonald, et al. Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus. Ann Surg. 1995 Sep; 222(3): 339–352.
5. Buchwald H, Varco RL, Matts JP, et al. Effect of partial ileal bypass surgery on mortality and morbidity from coronary heart disease in patients with hypercholesterolemia. Report of the Program on the Surgical Control of the Hyperlipidemias (POSCH). N Engl J Med. 1990;323:946–955.
6. Scopinaro N, Adami GF, Marinari GM, et al. Biliopancreatic diversion. World J Surg. 1998;22:936–946.