The History of Bariatric Surgery: Innovations in Weight Loss Surgery

| June 1, 2015

by George L. Blackburn, MD, PhD, MS, FACS

Bariatric Times. 2015;12(6):12–15.

This column is dedicated to to telling the stories of leaders who have helped shaped the field of bariatric surgery through their discoveries, teaching, and stewardship.

Column Editor: George L. Blackburn, MD, PhD, FACS
S. Daniel Abraham Professor of Nutrition; Associate Director,
Division of Nutrition Harvard Medical School; Director, Center for the Study of Nutrition Medicine, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts

Column Editor: Daniel B. Jones, MD, MS, FACS
Professor of Surgery, Harvard Medical School, Vice Chair, Beth Israel Deaconess Medical Center, Boston, Massachusetts

 


A Message from the Column Editors

Dear Readers of Bariatric Times:

Bariatric Surgery has many leaders who have helped shaped the field by their discoveries, teaching, and stewardship. Bariatric Times has initiated a new regular column titled, “The History of Bariatric Surgery—As Told by the Leaders Who Made it Happen.” We invite leaders to tell us about their most significant accomplishment(s). Here, we will hear from leaders about their visions, hurdles, collaborators, and, ultimately what impact their accomplishments had on the field of bariatric surgery. We will also learn how they set goals and turned ideas into reality, and what was anticipated and what was not expected throughout their journeys.
We are very excited about this project and hope it will help to inspire the next generation of leaders as they evaluate new devices and technology, and consider novel procedures and treatments in an era of cost containment. We hope you enjoy these stories.

Sincerely,
Dr. Daniel B. Jones


The history of bariatric surgery, like that of surgery itself, has been defined by innovators[1]—visionaries who took risks and made life or death decisions in a field in which such decisions are made every day.

In the weight loss surgery arena, Dr. Edward Mason[2] and many other luminaries have taken risks and made invaluable contributions ( “href=”http://bariatrictimes.com/wp-content/uploads/blackburn_table1.jpg”>Table 1). I’ve followed their lead, working with colleagues to advance nutrition science and the treatment of obesity.

My first experience with weight loss surgery was in 1964. I was in my third year of medical school and a student research fellow in Professor Paul Schloerb’s surgical metabolism laboratory. I was doing a rotation through the National Institutes of Health (NIH) Clinical Research Center (CRC) at the University of Kansas when a super-obese patient (BMI 61kg/m2) who’d undergone jejunal-ileal bypass surgery died from malnutrition and electrolyte imbalances. That’s when I lost all interest in the procedure itself as well as the field of weight loss surgery.

The following year, when I joined the Fifth Harvard Surgical Service at Boston City Hospital, Boston, Massachusetts, I focused on the nutritional requirements of malnourished patients who couldn’t eat, but whose lives could be saved by hyperalimentation. However, we had yet to determine the means to deliver required nutrients, or the optimal combination of protein and calories.

A medical student from the University of Pennsylvania in Philadelphia, Pennsylvania, who was working in the surgical laboratories with Dr. Stanley Dudrick,[3] gave us the means—a subclavian central venous catheter that could be used to administer a sterile, nutritionally complete intravenous feeding. In time, I developed the way to derive the optimal combination of macro- and micronutrients.

This happened after the chief of surgery, Dr. William McDermott, arranged for me to work in the Massachusetts Institute of Technology (MIT) Unit of Experimental Medicine in the Department of Nutrition and Food Science. It was there, with access to CRCs at Boston City Hospital and MIT, that I started to develop my PhD thesis on the protein sparing modified fast (PSMF).

My research made it possible to determine the protein and caloric requirements for patients receiving enteral and total parenteral nutrition (TPN). This work became the cornerstone for the metabolic criteria to administer both TPN therapy and obesity treatment. Its findings were used to establish guidelines that became the universally accepted norm in patient care.

In 1970, I worked with Dr. Bruce Bistrian at the Deaconess Hospital in Boston, Massachusetts, as the co-director of the Nutrition Support Service (NSS). Together, we sparked a revolution in the delivery of enteral and parental nutrition by establishing a dedicated multidisciplinary NSS team made up of surgeons, physicians, nurses, pharmacists, and dietitians.

At the time, protein-calorie malnutrition was widespread. Our research showed that it affected 50 percent of medical and surgical patients in municipal hospitals,[4] an outcome that drew attention to the issue and changed the practice of nutritional support around the world.

Our team approach served as the model for dedicated NSS teams. It was put into place at Boston City Hospital and the Harvard-affiliated Deaconess Hospital. It was adopted at all Harvard teaching hospitals, and eventually became the standard for NSS in hospitals throughout America and overseas.

My work and that of my colleagues in advancing the basic science and treatment of malnutrition led the way to major parallel progress in the biology and treatment of obesity. The metabolic, physiologic, and clinical concepts associated with malnutrition in hospitalized patients readily translated into obesity research.

This transfer of scientific and clinical knowledge moved both fields forward and spurred the establishment of North American and international professional societies, such as the American Society of Parenteral and Enteral Nutrition (ASPEN), The Obesity Society (TOS), the American Society for Nutrition (ASN), the American Society for Clinical Nutrition, and the European Society for Parenteral and Enteral Nutrition (ESPEN)—organizations that are crucial to the promotion of obesity awareness and research into critical issues.

Their founding relates to the evolution of weight loss surgery in a somewhat circuitous way. Dr. Joel Freeman, one of our former surgical fellows, took an academic position at the University of Iowa, Iowa City, Iowa, where he introduced parenteral nutrition. He invited me to visit circa 1973 to give a lecture on hospital malnutrition and the use of TPN.

This is where I met Dr. Mason. He’d designed and developed gastric bypass surgery starting in 1967. By the early 1970s, he had gone through many iterations of the Roux-en-Y gastric bypass (RYGB). I immediately invited him to Boston as a visiting surgeon to perform RYGB in our severely obese subjects who were intractable to medical nutrition treatment/therapy (MNT).

RYGB was an innovation that rekindled my interest in surgical treatment for obesity and increased my determination to help intractably obese patients reclaim their lives. I was the first surgeon in New England to perform the procedure, and was more than happy to see jejunal-ileal bypass phased out of practice. This new operation improved patient safety and outcomes, and is now the gold standard.

But it wasn’t developed in isolation. Dr. Mason’s achievements resulted from multiple collaborations that eventually led to a small interdisciplinary team of select researchers, surgeons, physicians, and biochemists. Working together, they spearheaded and refined gastric bypass and the RYGB procedure. Group presentations of findings from other national and international pioneers quickened the pace of changes that improved the efficacy and safety of surgical practice. They also launched the American Society for Metabolic and Bariatric Surgery (ASMBS) in 1983.

Today, surgeons and scientists still discuss each other’s research, new developments, techniques, and solutions at regional surgical society meetings. This exchange of ideas and data is as critical to progress now as it was when Dr. Bistrian and I developed TPN3 or when Dr. Mason was honing RYGB.[2] Science doesn’t advance in a vacuum, nor do breakthroughs in surgical care.

With the introduction of RYGB, demand for weight loss surgery ballooned 625 percent between the early 1990s and 2003. Any surgeon could enter the field, putting patients in jeopardy by increasing the probability of risks and complications. In 2004, the Commonwealth of Massachusetts convened an Expert Panel to study weight loss surgery as it related to patient safety.[5] We were charged with reviewing procedures, identifying potential safety issues, and making recommendations to reduce medical errors and improve the safety and well-being of bariatric surgery patients.

Working under the auspices of the Commonwealth’s Betsy Lehman Center for Patient Safety and the Reduction of Medical Errors, I had the honor of serving as Co-Chair of the first Expert Panel as well as Chair of the Updated Evidence-based Recommendations for Best Practices in Weight Loss Surgery, which was published in Obesity in 2009 ( “href=”http://bariatrictimes.com/wp-content/uploads/blackburn1.jpg”>Figure 1).[6] The first Lehman Center guidelines were developed by a dedicated group of over 80 of the state’s obesity experts and healthcare professionals. The second grew to include over 11 disciplines covering every aspect of weight loss surgery ( “href=”http://bariatrictimes.com/wp-content/uploads/blackburn-table-2.jpg”>Table 2).

This work changed preoperative screening, perioperative procedures, and postoperative care of weight loss surgery patients. Its findings were picked up by the Agency for Healthcare Research and Quality (AHRQ) and had a wide-ranging impact on the practice of bariatric surgery in Massachusetts and nationwide. They set the standard of care to include multidisciplinary treatment teams and formed the basis for accreditation by the ASMBS and the American College of Surgeons (ACS).

In 2005, we developed the Harvard continuing medical education (CME) program “Patient Safety in Obesity Surgery,” under the leadership of Dr. Daniel Jones, chief of minimally invasive surgery at Boston’s Beth Israel Deaconess Medical Center (BIDMC). This unique course invited not only surgeons as speakers, but also scientists, lawyers, government representatives, members of the media, and insurance company executives—all those affected by weight loss surgery and the obstacles that blocked the delivery of safe and effective care for patients with severe obesity.[7]

Eradicating those obstacles was also one of the goals of a Harvard Medical School CME program, “Practical Approaches to the Treatment of Obesity,” which I had the privilege of directing for 25 years. This CME course educated countless numbers of practitioners, and continues today as the “Blackburn International Conference on Practical Approaches to the Treatment of Obesity.” Its leadership includes Drs. Lee Kaplan and Caroline Apovian, respective directors of weight loss clinics at Massachusetts General Hospital and Boston Medical Center.

For all of its challenges, or perhaps because of them, obesity remains a major focus of my basic, clinical, and translational research. As scientific director and founder of the Center for the Study of Nutrition Medicine (CSNM) at BIDMC, I’ve worked with many colleagues to identify weight loss goals for the treatment of cardiovascular disease as well as biomarkers (e.g., blood pressure, lipid profiles, and hyperinsulinemia) of obesity-related comorbidities. These efforts have shaped public policy, evidence-based guidelines, and clinical practice.

Obesity is one of the most refractory diseases in the United States and worldwide. Lifestyle change, the current first-line treatment strategy, has notoriously high recidivism rates and interindividual variability. Large prospective cohort studies, such as the NIH-funded Look AHEAD trial, have been seeking ways to improve both short- and long-term outcomes.

As a Look AHEAD investigator for the past 12 years, I’ve seen the difference that an intensive lifestyle intervention (ILI) can make compared with standard diabetes support and education (DSE). At one year, the ILI participants lost an average of 8.6 percent of their initial weight versus 0.7 percent in the DSE group.[8] A recent publication of eight-year findings9 showed that the Look AHEAD ILI group had achieved and maintained clinically significant weight loss (>5%) in 50 percent of the participants with type 2 diabetes.

Look AHEAD, the largest and longest randomized evaluation to date of an intensive lifestyle intervention for weight reduction,[8,9] is slated for a competing five-year renewal to conduct critical new research studies in this aging patient population. We’re preparing for that now.

In addition to Look AHEAD, my most recent collaborations are with the next generation of obesity treatment specialists. I’m working with BIDMC’s Dr. Christina Wee on the use of health utility assessment to measure the value patients place on weight loss and how much risk they are willing to take to achieve their weight loss goals.[10]

Research into the neurocognitive underpinnings of human eating behavior is another critical scientific endeavor. My collaboration with my BIDMC colleague, Dr. Miguel Alonso-Alonso, focuses on what is still an incomplete understanding of food intake regulation. It involves complex integration between brain circuits related to cognition, homeostasis, and reward.

It has taken 61 years—from the start of weight loss surgery until today—to acknowledge obesity as a disease, and just as long to recognize fat mass as an endocrine organ that predisposes those who suffer from obesity to insulin resistance. It’s time to develop an insulin sensitivity test and a way to restore the proper function of pancreatic beta cells.

My current goals include the pursuit of neurocognitive approaches to promote weight loss through lifestyle changes, the development of new surgical procedures that achieve desired medical and metabolic outcomes, and the opening of doors to the less radical treatment of obesity through combinations of behavioral changes and drug therapy.

Dramatic increases in population-wide obesity have led to a global public health crisis that demands the best that those of us in the fields of science and medicine can offer to treat the disease, and alleviate the pain and suffering of those afflicted by it.

“href=”http://bariatrictimes.com/wp-content/uploads/blackburn2.jpg”>Figure 2: Blackburn GL, Corliss J. Break Through Your Set Point: How to Finally Lose the Weight You Want and Keep It Off. New York, New York: HarperCollins Publishers; 2007.

References
1.    Riskin DJ, Longaker MT, Gertner M, Krummel TM. Innovation in surgery: a historical perspective. Ann Surg. 2006;244:686–693.
2.    Blackburn GL. The 2008 Edward E. Mason Founders lecture: interdisciplinary teams in the development of “best practice” obesity surgery. Surg Obes Relat Dis. 2008(4);679–684.
3.    Blackburn GL, Wollner S, Bistrian BR. Nutrition support in the intensive care unit: an evolving science. Arch Surg. 2010;145:533–538.
4.    Bistrian BR, Blackburn GL, Vitale J, Cochran D, Naylor J. Prevalence of malnutrition in general medical patients. JAMA. 1976;235:1567–1570.
5.    Blackburn GL, Hu FB, Harvey AM. Evidence-based recommendations for best practices in weight loss surgery. Obes Res. 2005;13:203–204.
6.    Blackburn GL, Hu FB, Hutter MM. Updated evidence-based recommendations for best practices in weight loss surgery. Obesity (Silver Spring). 2009;17:839-841.
7.    Jones SB, Jones DB, eds. Obesity Surgery: Patient Safety and Best Practices. Woodbury, CT: Cine-Med, Inc.; 2009.
8.    Look AHEAD Research Group, Pi-Sunyer X, Blackburn G, et al. Reduction in weight and cardiovascular disease risk factors in individuals with type 2 diabetes: one-year results of the look AHEAD trial. Diabetes Care. 2007;30:1374-1383.
9.    Look AHEAD Research Group. Eight-year weight losses with an intensive lifestyle intervention: the Look AHEAD study. Obesity (Silver Spring). 2014;22:5-13.
10.    Wee CC, Hamel MB, Apovian CM, et al. Expectations for weight loss and willingness to accept risk among patients seeking weight loss surgery. JAMA Surg. 2013;148(3):264-271

FUNDING: No funding was provided.

FINANCIAL DISCLOSURES: The author reports no conflicts of interest relevant to the content of this article.

 

 

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Category: Past Articles, The History of Bariatric Surgery

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