The History of Bariatric Surgery: A Life in Metabolic Surgery

| September 1, 2015

by Mervyn Deitel, MD, FASMBS, FACN, CRCSc, FICS

Dr. Deitel pioneered intravenous hyper-alimentation (total parenteral nutrition) at St. Joseph’s Health Centre in Toronto in 1967 and began bariatric surgery in 1970, becoming a Professor of Nutritional Sciences and Surgery at University of Toronto, performing 2,850 jejuno-ileal bypasses, gastroplasties, and Roux-en-Y gastric bypasses. Starting in the 1970s, he edited five textbooks on surgical nutrition and on bariatric surgery. He was a Founding Member of the American Society for Bariatric Surgery (ASBS) in 1983, and served as President of the ASBS in 1994–1995. He was awarded the Outstanding Achievement Award of the ASBS Foundation in 2002. He was the Founding Editor of the journal Obesity Surgery in 1991, and Editor-in-Chief of the journal from 1991 to 2008, and remains Emeritus Editor-in-Chief. He was a Founding Member of the International Federation for the Surgery of Obesity (IFSO) in 1996, served as its first Executive Director, and was awarded the Golden IFSO Logo in 1999 and Life Membership in 2005. He has published more than 350 articles (196 indexed in the Index Medicus, www.PubMed.gov), authored 14 chapters, serves on the editorial board of five journals, and has made more than 500 presentations, many invited abroad. He is a member of the Central Surgical Association, Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), Society for Surgical Oncology, American Head and Neck Society, American College of Nutrition, Canadian Association of General Surgeons, and a Past-President of the Roswell Park Surgical Society. He is Chief of the Advisory Board of the International Bariatric Club.

Bariatric Times. 2015;12(9): 10–12.

This column is dedicated to telling the stories of leaders who have helped shape 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 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, collaborations, and, ultimately what impact their accomplishments have had on the field of bariatric surgery. We will also learn how they set goals and have turned ideas into reality, as well as 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,
Drs. George L. Blackburn and Daniel B. Jones


I  was born in Toronto, Canada, and graduated from University of Toronto in 1961. After interning at Mount Sinai Toronto, and eventually becoming Chief Resident in Surgery at New York University/Beth Israel Medical Center, New York, New York, I trained for a year at the New York State Cancer Hospital Roswell Park, Buffalo, New York. I later became President of the Roswell Park Surgical Society. I then trained in Trauma at Parkland Memorial Hospital in Dallas, Texas.

Upon my return to Toronto to treat trauma and cancer (many head and neck papers resulted), I was most impressed with starvation problems and patients enduring fistulas and inflammatory bowel disease who were referred to my intensive care unit. In 1967, I initiated a system of total parenteral nutrition (TPN) in Canada, treating a multitude of starving patients requiring specialized nutritional support.[1–7] Our studies led to development of elemental and chemically defined diets for industry.[8] A striking memory is a 500-gm immature infant whom I supported with TPN down the internal jugular, until he could eat on his own1; he is a healthy 49-year old today. I also developed enteral feeding down fine (like a noodle) silicone tubes by passing a retrievable angiographic guide-wire into the tube9; this led to production of fine feeding tubes.

Likely because of my experience treating malnutrition, in 1970, I started to get referrals for patients suffering from massive obesity with serious comorbidities. I started with the jejuno-ileal bypass (JIB), and found that these patients had permanent cure of diabetes.10 The later finding by Erik Naslund of the glucagon-like peptide-1 (GLP-1) incretin in the distal small bowel when nondigested food was presented to it explained this finding. I followed my JIB patients into old age, and many outlived their spouses.[11] Studies on fat cells from my patients led later to discovery of leptin.[12,13]

The JIB occasionally led to migratory arthralgias and gas-bloat syndrome—eradicated by metronidazole. Liver problems were prevented by daily Na L-methionine pills (lipotropic factor); however, renal calcium oxalate stones developed in six percent of JIB patients, which necessitated revision.[11]

Accordingly, I switched to the various restrictive gastroplasties, which showed good weight loss initially, followed by dilatation of the pouch and outlet. The vertical banded gastroplasty (VBG) then became popular, but after a number of years, we confirmed that the channel frequently enlarged, with regain.

There was need for an annual colloquium, spearheaded by the great Dr. Edward Mason. I was a Founding Member of the American Society for Bariatric Surgery (ASBS) in Iowa in 1983. I was President of the ASBS in 1994, and was gratified to receive the Outstanding Achievement Award of the American Society for metabolic and Bariatric Surgery (ASMBS) Foundation in 2005. I transitioned to the Roux-en-Y gastric bypass (RYGB), which I found to achieve excellent weight loss, but it occasionally resulted in probems, including stomal ulcers, obstructing internal hernias, hypoglycemia, malnutrition, and later weight regain (pouch and stomal enlargement).

We also benefitted from an annual International Obesity Symposium under Prof. Nicola Scopinaro (the pioneer of the BPD), and in 1995, a dedicated group formed the The International Federation for the Surgery of Obesity (IFSO [CoverFigure 1]). I was the Executive Director of IFSO for its initial seven years. IFSO’s rise has been phenomenal. I was fortunate to be awarded the IFSO gold pin in 1998 and Honorary Life Membership in IFSO (permanent Councilor).

Bariatric surgeons had many important papers refused by general surgery journals. Thus, in 1991, despite considerable opposition, I started the journal Obesity Surgery. Some complained that we would show the field as unscientific. I applied to many publishers, and finally travelled to England, where a new publisher, Rapid Communications of Oxford, which later became International Thomson Publications, was willing to undertake the journal (CoverFigure 2).  There was a flood of papers, but when the publisher sold the journal to JP Lippincott, it became a financial failure. In 1998, when the journal was about to be abandoned, we took over Obesity Surgery as part of FD (Frances Deitel) Communications Inc. I labored intensively to build international circulation, and undertook the editing, design, binding, polybagging, mailing, advertising, and reprints. In 2004, the journal achieved an impact ranking of 7 out of 149 surgical journals in the world for three years. To continue this success, a major publishing house, Springer Science, acquired the journal in 2006, and it has been able to continue successfully as the official journal of IFSO. I was Editor-in-Chief from 1991 to 2008, during which my studies included related gallstone formation, sleep disorders, cardiac function, fatty liver, obstetrics, osteoarthritis, and ultra-obesity.[14–19]

During these years, I published five textbooks, the first was Nutrition in Clinical Surgery in 1974 and the last being Handbook of Obesity Surgery in 2010, which have been read throughout the bariatric world. I was also fortunate to publish 21 chapters and contribute to 196 papers on PubMed, and maintain a particular interest in diabetes.[20,21]

I helped write the first four consensus conferences on sleeve gastrectomy (SG). SG initially appeared to be a very good operation on its own;[22] however, high leaks, fistulas, Wernicke’s, gastroesophageal reflux and Barrett’s esophagus, as well as enlargement of the pouch after five years (if all patients are followed) have indicated that more must be done with this procedure[23]—either a duodenal switch, or a mini-gastric bypass (with a long channel to below crow’s foot).

After experience with the RYGB, Dr. Robert Rutledge developed the one-anastomosis mini gastric bypass (MGB) in 1997, and received skepticism. Thus, I spent considerable time as his guest in his operating room and clinics. I was invited to international consensuses, and believe that currently the MGB, if performed correctly, is a safe, rapid procedure, with few complications, revisable, reversible, with durable weight loss, compared to other operations.[24–29]

The beat goes on, and the obesity epidemic remains a challenge.[30] Meanwhile, I have been blessed with a lovely intelligent wife, who has enabled my endeavors during our 53 years of marriage. Our two sons are doctors —a radiologist in Toronto and a spinal surgeon in California. I pass through old age and look back on the challenges of nutritional and metabolic surgery,[31] and for the time being, I am able to be active in a number of international invited courses.

References
1.    Deitel M, Sanderson I, Petsoulas T. A system of intravenous hyperalimentation. Internat Surg. 1973;58:670–675.
2.    Sanderson I, Deitel M. Intravenous hyperalimentation without sepsis. Surg Gynecol Obstet. 1973;136;577–585.
3.    Deitel M, Kaminsky V. Osmolality of hyperalimentation solution infused into  the superior vena cava. Can J Surg. 1974;17:310–312.
4.    Sanderson I, Deitel M. Insulin response in patients receiving concentrated infusions of glucose and casein hydrolysate for complete parenteral nutrition. Ann Surg. 1974;179:387–394.
5.    Deitel M Kaminsky V, Fuksa M. Growth of common bacteria and Candida albicans in 10% soybean oil emulsion. Can J Surg. 1975;18:531–535.
6.    Deitel M, Vasic V, Alexander M. Specialized nutritional support and cancer. JPEN J Parenter Enteral Nutr. 1978;2(5):671–675.
7.    Deitel M. Nutritional management of external gastrointestinal fistulas. Can J Surg. 1976;19:505–511.
8.    Deitel M. Elemental diet and enterocutaneous fistula. World J Surg. 1983;7:451–454.
9.    Bojm MA, Deitel M. An easy method for passing fine silicone nasogastric tubes. Am J Surg. 1982;143:385.
10.    Sanderson I, Deitel M, Bojm MA. The handling of glucose and insulin response before and after weight loss with jejuno-ileal bypass. JPEN J Parenter Enteral Nutr. 1983;7(3):274–276
11.    Deitel M, Shahi B, Anand PK, Deitel FH, Cardinell DL. Long-term outcome in a series of jejunoileal bypass patients. Obes Surg. 1993;3:247–252.
12.    Kidron M, Hamilton BS, Kwan AY, Deitel M, Roncari DA. The effect of basic fibroblast growth factor on the reversion of omental adipocytes from lean and obese patients. Obes Surg. 1995;5:5–10.
13.    Teichert-Kuliszewska K, Hamilton BS, Roncari DA, Kirkland JL, Gillon WS, Deitel M, Hollenberg CH. Increasing vimentin expression associated with differentiation of human and rat preadipocytes. Int J Obes Relat Metab Disord. 1996;20(Suppl 3):S108–113.
14.    Deitel M, Petrov I. Incidence of symptomatic gallstones after bariatric operations. Surg Gynecol Obstet. 1987;164:549–552.
15.    Deitel M, To TB, Stone E, Sutherland DJ, Wilk EJ. Sex hormonal changes accompanying loss of massive excess weight. Gastroenterol Clin North Am. 1987;16:511–515.
16.    Herrera MF, Deitel M. Cardiac function in massively obese patients and the effect of weight loss. Can J Surg. 1991;34:431–434.
17.    Deitel M, Melissas J. The origin of the word “bari”. Obes Surg. 2005;15:1005–1008.
18.    Deitel M, Gawdat K, Melissas J. Reporting weight loss 2007. Obes Surg. 2007;17:565–568.
19.    Deitel M, Deitel KM, Deitel WL. Orthopedic considerations in the obese and the effect of bariatric surgery. In: Deitel M, Gagner M, Dixon JB, Himpens J, eds. Handbook of Obesity Surgery. Toronto: FD-Communications 2010: 406–409.
20.    Deitel M. Slow-progression, autoimmune, type 1 diabetes in adults: a cause of failure of resolution of diabetes after bariatric surgery. Surg Obes Relat Dis. 2009;5:705–706.
21.    Deitel M. Update: Why diabetes does not resolve in some patients after bariatric surgery. Obes Surg. 2011;21:794–796.
22.    Deitel M, Gagner M, Erickson AL, Crosby RD. Third International Summit: Current status of sleeve gastrectomy. Surg Obes Relat Dis. 2011;7:749–759.
23.    Gagner M, Deitel M, Erickson AL, Crosby RD. Survey on laparoscopic sleeve gastrectomy (LSG) at the Fourth International Consensus Summit on Sleeve Gastrectomy. Obes Surg. 2013;23:2013–2017.
24.    Lee WJ, Ser KH, Lee YC, Tsou JJ, Chen SC, Chen JC. Laparoscopic Roux-en-Y vs mini-gastric bypass for the treatment of morbid obesity: a 10-year experience. Obes Surg. 2012;22:1827–1834.
25.    Milone M, Di Minno MN, Leongito M, Maietta P, Bianco P, Taffuri C et al. Bariatric surgery and diabetes remission: sleeve gastrectomy or mini-gastric bypass? World J Gastroenterol. 2013;19:6590–6597.
26.    Disse E, Pasquer A, Espalieu P, Poncet G, Gouillat C, Robert M. Greater weight loss with the omega loop bypass compared to Roux-en-Y gastric bypass: a comparative study. Obes Surg. 2014;24:841–846.
27.    Rutledge R, Kular KS, Marchanda N, Bandari M, Goel R. A comparison of the outcomes of revision of the Roux-en-Y (RNY) and mini-gastric bypass (MGB): hard vs easy. Eur J Endosc Laparosc Surg. 2014;1:1–6.
28.    Georgiadou D, Sergentans TN, Nixon A, Dimantis T, Tsigris C, Pasaltopolau T. Efficacy and safety of laparoscopic mini-gastric bypass; a systematic review. Surg Obes Relat Dis. 2014;10:984–991.
29.    Rutledge R, Kular KS, Deitel M. Laparoscopic mini-gastric (one- anastomosis) bypass surgery. Chapt 43. In: Agrawal S, ed. Obesity, Bariatric and Metabolic Surgery: A Practical Guide. Springer International Publishing. August 2015.
30.    Deitel M. It’s a fat, fat, fat, fat world! Obes Surg. 2004;14:869–870.
31.    Deitel M. A brief history of the surgery for obesity to the present, with an overview of nutritional implications. J Am Coll Nutr. 2013;32:136–142.

FUNDING: No funding was provided.

FINANCIAL DISCLOSURES: Dr. Deitel reports no conflicts relevant to the content of this article.

Author affiliation: Dr. Mervyn Deitel is Editor-in-Chief Emeritus for Obesity Surgery and Senior Advisor for the International Bariatric Club.

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Category: Past Articles, The History of Bariatric Surgery

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