Metabolic Surgery: A Revolution or an Evolution?

| October 8, 2015

This column is dedicated to sharing the vast knowledge and opinions of the American Society for Metabolic and Bariatric Surgery leadership on relevant topics in the field of bariatric surgery.

This month: METABOLIC SURGERY: A Revolution or an Evolution?

Henry Buchwald, MD, PhD, FACS, HonFRCS
Professor of Surgery and Biomedical Engineering,
Owen H. & Sarah Davidson Wangensteen Chair in Experimental Surgery, Emeritus, University of Minnesota. Dr. Buchwald was President of the American Society for Metabolic and Bariatric Surgery from 1998 to 1999.

Bariatric Times. 2015;12(10):24–26.


 

Dr. Rosenthal: Since when were bariatric surgeons aware of the metabolic effects of bariatric procedures on diabetes?

Dr. Buchwald: When a caveman first drained a carbuncle with his stone knife, he was not aware that he was performing incisional surgery. When Ephram McDowell in 1809 first successfully removed a huge ovarian tumor on his kitchen table, without the benefit of anesthesia, he was not aware that he was performing extirpative surgery. When David Hale Williams, an African-American surgeon from Chicago, Illinois, closed a stab wound, which was actually the performance of the first successful open-heart procedure in 1893, and when the cardiac surgeons of the 20th century performed congenital, acquired valvular, and coronary artery surgery, they all were not aware or proclaiming that they had entered the era of reparative surgery. As surgery has progressed and different specialties have been added to it, including incisional, extirpative, reparative, reconstructive, and transplant procedures, the era of metabolic surgery, comparable to its predecessors, entered surgical practice with its practitioners unaware that they were engaging in a new discipline. In 1978, years after the initiation of metabolic surgery, Richard Varco and I defined this craft as “the operative manipulation of a normal organ or organ system to achieve a biological result for a potential health gain.”[1]

As early as 1896, regression of breast carcinoma metastases was induced by a bilateral oophorectomy. During the late 19th and early 20th centuries, the best known historical example of metabolic surgery came into existence—the curing of distal duodenal ulcers by operations on proximal normal stomach and vagal nerves. Partial ileal bypass, first introduced between 1962 and 1963,[2] and used as the intervention modality in the Program on the Surgical Control of the Hyperlipidemias (POSCH) trial,[3] further heralded metabolic surgery. The origin of bariatric surgery in 1953, and its evolution to the myriad of bariatric operations past,[4] and in practice today,[5] are all part and parcel of metabolic surgery. Yet, only relatively recently have bariatric surgeons considered themselves metabolic surgeons, and this revelation came about by awareness of the effects of bariatric procedures on type 2 diabetes mellitus (T2DM).

Resolution of T2DM by bariatric operations was clearly demonstrated by the mid-1990s by two of the great pioneers of metabolic/bariatric surgery. Scopinaro, in a carefully executed physiologic study, demonstrated the beneficial effects of biliopancreatic diversion on T2DM.[6] Pories reported the pre-weight loss disappearance of T2DM clinically and by laboratory parameters in patients after gastric bypass in a paper provocatively titled, “Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus.”[7] Our meta-analysis in 2004 provided irrefutable data to substantiate that bariatric surgery is metabolic surgery by reversing the metabolic diseases of T2DM, hypertension, and hyperlipidemia.[8] The slow process of realization of the association between bariatric surgery and metabolic diseases was greatly accelerated by the recent operative innovations to ameliorate T2DM by gastrointestinal procedures that do not cause weight loss.[9–11] The 2015 World Congress of the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) in Vienna, Austria, under the guidance of IFSO President Rudolf Weiner and meeting president Karl Miller, provided a major forum for accepting bariatric surgery as one aspect of metabolic surgery and embracing a larger concept for our discipline.

Dr. Rosenthal: What are the reasons for the new trend in identifying metabolic surgery as a different specialty?

Dr. Buchwald: There are two reasons for this basic transformation: Intellectually, it is warranted. Practically, it may be necessary.

First, bariatric surgery is, and has always been, “metabolic surgery.” Thus, metabolic surgery is not a different specialty, but rather an inclusive designation that encompasses bariatric surgery, and, importantly, allows for extension of this discipline to other areas of metabolic intervention, e.g., diabetes therapy without weight loss; treatment of hypertension, hyperlipidemia, and pseudotumor cerebri; electronic vagal nerve pacing for refractory depression, and, most significantly, expansion of innovative surgical procedures for a metabolic gain away from the abdominal cavity.

The practical reason is a sad one. Even in the light of a world epidemic of obesity and the designation of obesity as a disease by the American Medical Association,[12] the disease concept of obesity has not been accepted by many private providers, national health funding programs, numerous hospital administrations, a large number of medical practitioners, including surgeons; and, most importantly, the majority of the public. In the United States, the Affordable Care Act (ObamaCare) excludes bariatric surgery and has allowed 28 states to remove bariatric surgery from their list of mandated procedures. The National Institutes of Health (NIH) has never been supportive of bariatric surgery research or even recognition of the legitimacy of bariatric surgery. This status of neglect and even derision has now been in existence for over 60 years. No other major surgical discipline that can benefit myriads of people has been treated so shamefully. Open-heart surgery and transplantation surgery faced opposition at their origins, but this sentiment rapidly gave way to acceptance and even adulation.

Prejudice against individuals with obesity is solidly entrenched and, at times, seems to be immutably engrained. Thus, the practical reason for identifying metabolic surgery as a different specialty does not equate to stopping our fight against the persistent bias toward individuals with obesity but, for the sake of our patients, taking the fight to battlefields more conducive to victory and within the approbation of the public—the amelioration of T2DM, coronary heart disease, and so on.

Dr. Rosenthal: How would you incorporate the new knowledge we have about the metabolic effects of weight loss surgery into our bariatric armamentarium?

Dr. Buchwald: In essence, we have already done this. In 2007, the word metabolic was added to the American Society for Bariatric Surgery making it the American Society for Metabolic and Bariatric Surgery (ASMBS). IFSO also added Metabolic Disorders to its name. Simplistically, all that is now necessary is to change the term “bariatric surgery,” as well as its implications, to metabolic/bariatric surgery. By doing so we will have changed the name of our discipline and incorporated metabolic cognizance into our therapeutic armamentarium.

But let us look at this transition in a broader sense. Pharmaceutical research is the search for an unifocal effect (function agonist, antagonist, replacement) with minimal or no scattered influence on other bodily processes that clinically can translate into side effects and complications. Contrary to this focused orientation, metabolic/bariatric surgery has been successful because of its induction of multiple pathways of automedication by several neuroendocrine pathways, which combat complex, multifactorial diseases. Annually, we have hundreds of thousands of new and follow-up metabolic/bariatric surgery patients for study in a human laboratory, free of the restraints of having to raise huge amounts of research monies. What we learn about hormonal and neural networks clinically can be taken to the basic research laboratory for more specific analysis. Translational research is not a one-way process, but rather a back-and-forth conversation between the laboratory and clinical application. If we as metabolic/bariatric surgeons assume responsibility for generating basic insights into the pathways that can ameliorate T2DM and other metabolic diseases, we may actually elucidate the mechanisms for the etiology of diabetes, other metabolic afflictions, and obesity itself. In order for this research to achieve maximum success, we should be joined in our efforts in exploring the metabolic effects of weight loss surgery by endocrinologists and other nonsurgeon clinicians and basic scientists. What a waste of time and human resources we have expended in the past and, unfortunately, in current battles between metabolic/bariatric surgeons and our detractors.

Our expanding metabolic knowledge is the basis for new procedures in our metabolic/bariatric armamentarium. We are exploring original surgical venues to cure metabolic diseases, with and without weight loss. We are expanding our utilization of barrier and electronic devices with a metabolic focus. Our operative procedures have always been assessed for safety, complications, time, cost, and the percent excess body weight loss achieved. We have added to these assessors the metabolic effects induced by our procedures, and these attributes now often supersede in our analysis the weight loss attained. This transition in emphasis has, in fact, incorporated our knowledge of metabolic effects into our bariatric, or better, metabolic/bariatric armamentarium.

Dr. Rosenthal: Do you believe there is a need for a new society or specialty?

Dr. Buchwald: Society—no; specialty—no.
I believe that we have adequately covered the fact that the specialty of metabolic/bariatric surgery has been established, and that we, as metabolic/bariatric surgeons, are today in the forefront of the era of metabolic surgery. ASMBS and IFSO, as well as the current, regional, originally bariatric societies, have fully embraced the concept of metabolic surgery in their mission and in their mandate. This conversion is strongly reflected in the topics and papers presented at their annual meetings. We have also discussed the fact that metabolic surgery has been in existence for a long time and did not start with bariatric surgery, which today is the best recognized and widely practiced aspect of this discipline.

In science and in clinical practice, we are always in a state of flux, hopefully translated into progress. This dynamic does not, however, call for a denial of past accomplishments and institutions. We need to expand our cognitive recognition of metabolic surgery and use the established strengths of our existent societies to proselytize our new potential.

Dr. Rosenthal: What are the risks and benefits if a new society develops?

Dr. Buchwald: For clarification, this question needs to be answered by another question: Will this new society be more encompassing or more narrowly focused?

Let us start with the former. A society for greater metabolic surgery would currently include the following: bariatric surgery, diabetes surgery, hyperlipidemia surgery, hypertension surgery, and aspects of endocrine, neuro, gynecologic, neurologic, and cardiovascular surgery. In the future, such a society would need to embrace bionic, implantation, genetic, and germ cell surgery, as well as new realms of intervention fulfilling the definition of metabolic surgery. In essence, with the exception of primarily extirpative cancer surgery and anatomic reconstructive surgery, such a new society would attempt to encompass far too many areas of interest. Further, such a new society would cross current lines of surgical specialization, infuriate existent specialty societies, and have great difficulty in being recognized by the encompassing national surgical bodies (e.g., American College of Surgeons). What I believe that advocates of a new metabolic surgery society are actually envisioning is a society of gastrointestinal surgeons performing metabolic procedures that include the management of obesity, diabetes, and certain other diseases. This transition is highly feasible and well underway within the current auspices of ASMBS and IFSO and does not require a new society.

The risks of establishing one or several smaller societies are also forbidding. For instance, exclusive emphasis on diabetes surgery is fraught with a lack of clarity of purpose, because T2DM cannot be fully separated from obesity by clinical, genetic, or environmental factors. If diabetes surgery is expanded out of gastrointestinal surgery (e.g., ablation of the pararenal vasculature network), it will again cross existent specialty lines and, thereby, achieve not cohesiveness but divisiveness. Further, super specialization brought to the level of a singular society may satisfy certain personal ambitions but would fracture and alienate the greater majority of active metabolic/bariatric surgery practitioners. Such a move could also severely damage the gains we have made for the treatment of individuals with obesity. I believe that the splintering of existent metabolic/bariatric societies will be viewed as a self-denial of the validity of our founding purpose, which is to care for patients with obesity using surgery.
Thus, I find few benefits for the creation of a new, super inclusive or exclusive society. A focused society emerging from our current societies may draw more immediate attention to a disease process; however, by the confusion and schism it would create, it can also do more harm than good. Let us give our international and national bariatric societies the opportunity to continue rationally to expand and to be inclusive, thereby avoiding the pitfalls of fragmentation.

References
1.    Buchwald H, Varco RL: Editors, Metabolic Surgery; Grune and Stratton, Publ, New York; 1978.
2.    Buchwald H. Lowering of cholesterol absorption and blood levels by ileal exclusion: Experimental basis and preliminary clinical report. Circulation. 1964;29:713–720.
3.    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.
4.    Buchwald H, Buchwald JN. Evolution of operative procedures for the management of morbid obesity 1950–2000. Obes Surg. 2002;12:705–717.
5.    Angrisani L, Santonicola A, Iovino P, Formisano G, Buchwald H, Scopinaro N. Bariatric surgery worldwide 2013. Obes Surg. 2015;25(10):1822–1832.
6.    Scopinaro N, Adami GF, Marinari GM, et al. Biliopancreatic diversion. World J Surg. 1998;22:936–946.
7.    Pories WJ, Swanson MS, MacDonald KG, et al. Who would have thought it? An operation proves to be the most effective therapy for adult-onset dibetes mellitus. Ann Surg. 1995;222:339–352.
8.    Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, Schoelles K. Bariatric Surgery: a systematic review and meta-analysis. JAMA. 2004; 292(14):1724–1737.
9.    Scopinaro N, Adami GF, Papadia FS, et al. Effects of biliopancreatic diversion on type 2 diabetes in patients with BMI 25 to 35. Ann Surg. 2011;253:699–703.
10.    Huang CK,  Goel R, Tai CM, Yen YC, Gohil VD, Chen XY. Novel metabolic surgery for type II diabetes mellitus: loop duodenojejunal bypass with sleeve gastrectomy. Surg Laparosc Endosc Pct Tech. 2013;23:481–485.
11.    Cohen RV, Neto MG, Correa JL, et al. A pilot study of the duodenal-jejunal bypass liner in low body mass index type 2 diabetes. J Clin Endocr Metabol. 2013;98:E279–E282.
12.    American Medical Association. Report 4 of the Council on Scientific Affairs (A-05). Recommendations for Physician and Community Collaboration on the Management of Obesity (Resolution 420, A-13), 2013. http://media.npr.org/documents/2013/jun/ama-resolution-obesity.pdf. Accessed July 9, 2015.

Funding: No funding was provided in the preparation of this manuscript.

Financial disclosures: The author reports no conflicts of interest relevant to the content of this article.

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