The History of Bariatric Surgery: What I Learned About Stomach Surgery

| May 1, 2015

by Edward E. Mason MD, PhD

Bariatric Times. 2015;12(5):14–15.

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.

Drs. George L. Blackburn and Daniel B. Jones

Idesigned gastric bypass as a reversible simplification of Owen H. Wangensteen’s modification of Billroth II gastrectomy. In 1965, I spent two weeks living in an empty (Fall vacation time) student dormitory, reading papers on stomach physiology and swimming in the pool. I attended a meeting on gastric physiology at the end of my retreat from Hay fever and came home with a plan for research of gastric bypass, which was to copy Billroth II gastrectomy from 1885, but leave the bypassed stomach in place. I was not thinking about what the operation might be used for at the time beyond treating peptic ulcer. Morbid obesity was infrequent at that time.

When I returned to Iowa City, I began a series of experiments with pouch dogs assisted by Chikashi Ito from Japan, who came to the United States with his family for three years to learn about America. He did not want to treat patients while here, but sought work in a surgical research laboratory. After one year of study in the animal laboratory, I began two studies in patients. Gastric bypass failed to resolve duodenal ulcer symptoms in six patients, but one patient who had obesity was relieved of ulcer symptoms and lost weight. I began treating obesity at the same time because patients with Billroth II gastrectomy often lost weight even when they were not obese. Beginning in 1967, I made use of an undesirable side effect of gastrectomy, to treat morbid obesity with Wangensteen’s modification of Billroth II gastrectomy but with the stomach left in place.

The stomach has two components—the Magenstrasse or sleeve and a distensible portion. Gastric bypass is functionally a total gastrectomy. After gastric bypass, the lesser curvature sleeve provides unregulated transit from the esophagus through the duodenum to the jejunum. In the beginning, patients were referred by friends and relatives for gastric bypass and then physicians began referring patients after failure of diet, exercise, and other forms of treatment.

I thought that restriction in eating was the cause of weight loss after gastrectomy and gastric bypass. Meal size was certainly reduced but it became evident that there was acceleration of whatever was well chewed and swallowed into the jejunum. This hypertonic content functions like milk of magnesia and, thus, stimulates a flush and secretion of glucagon-like peptide-1 (GLP-1) and other hormones, curing type 2 diabetes mellitus (T2DM). The hypertonic flush provides glucose and other stimulants to distal L cells. The mechanism of cure of T2DM became evident later as I learned more about investigations of T2DM.  T2DM is due to failure of secretion of GLP-1, and gastric bypass stimulates L cell secretion of this and other hormones including insulin. GLP-1 is an incretin.

As I look back over 50 years of study of the stomach, there are at least two major discoveries that I share with many general surgeons and other sufficiently curious students. First is the reversible gastric bypass with decreasing body weight when all else has failed. Second is the cure of T2DM by both intestinal and gastric bypass by exposure of L cells to glucose and other stimulants of secretion. I did not design gastric bypass to cure obesity. My original goal in designing gastric bypass was to provide a simple and reversible stomach operation to replace Billroth II gastrectomy.  Gastrectomy had been preventing and curing obesity for a century before anyone “discovered” it.

Sleeve gastrectomy has become popular, but it is irreversible. Elias Darido has performed animal research studies of this reversible operation,[1,2] which I believe will replace both gastric bypass and sleeve gastrectomy and should be applicable for at least two other stomach surgery diseases. Darido’s operation is fundic invagination with anastomosis to the antrum. I hope this will be my most recent and important discovery. I suggested calling it Darido’s invagination sleeve gastrotomy in keeping with current nomenclature and experience with irreversible sleeve gastrectomy.

I do not believe that I actually was the first or only person who made any discoveries. As many sources have said throughout history, “There is nothing new under the sun.” Each generation evolves in their experience and discovery of what is better or worse for our species and earth. I discover as I study and seek needed paradigm change. Of course, there is value in different view points as long as we recognize the limitations and the importance of shifting paradigms.

Read More: Dr. Mason on the creation of ASBS and its first meetings

References and resources
1.    Darido E, Moore JR. Comparison of gastric fundus invagination and gastric greater curvature plication for weight loss in a rat model of diet-induced obesity. Obes Surg. 2014 Jan 19 [Epub ahead of print]
2.    Darido E, Overby W, Brownley KA, et al. Evaluation of gastric fundus invagination for weight loss in a porcine model. Obes Surg. 2012; 22: 1293–1297.
3.    Sjöström L, Narbo K, Sjöström CD, et al. Effects of bariatric surgery on mortality in Swedish obese subjects. N Eng J Med. 2007;357:741–752.
4.    Jamieson AC. Determinants of weight loss after gastroplasty. In: Mason E, guest editor; Nyhus LM, editor-in-chief. Surgical Treatment of Morbid Obesity. Vol. 9. Philadelphia: JB Lippincott; 1992:290–297.
5.    Long M, Lindsey M. Development of long vertical gastroplasty. In: Mason E, guest editor; Nyhus LM, editor-in-chief. Surgical Treatment of Morbid Obesity. Vol. 9. Philadelphia: JB Lippincott; 1992;266–275.
6.    Tretbar LL,Taylor TT, Sifers EC. Weight reduction, gastric plication for morbid obesity. J Kansas Medical Society. 1976;77:488.
7.    Curley SA, Weaver W, Wilkinson LH, Demarest GB. Late complications after gastric reservoir reduction with external wrap. Arch Surg. 1987;122:781–783.
8.    Miholic J, Orskov C, Holst JJ, et al. Emptying of the gastric substitute, glucagon-like peptide-1 (GLP-1), and reactive hypoglycemia after total gastrectomy. Dig Dis Sci. 1991;36(10):1361–1370.
9.    Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med. 1998;14(4):245–258.
10.    Sarr M G. Noninsulinoma pancreatic hypoglycemia after Roux-en-Y gastric bypass: A more simple operative treatment. Bariatric Times. 2011;8(10):8–9.
11.    Schauer PR, Kahyap SR, Wolske K, et al. Bariatric surgery versus intensive medical therapy in obese patients with diabetes. N Eng J Med. 2012;366:1567–1576.
12.    Mingrone G, Panunzi S, Gaetano A, et al. Bariatric surgery versus conventional medical therapy for type 2 diabetes. N Engl J Med. 2012;366:1567–1576.
13.    Brener W, Hendrix TR, McHugh PR. Regulation of the gastric emptying of glucose. Gastroenterology. 1983; 85:76–82.
14.    Schirra J, Katschinski M, Weidmann C, et al. Gastric emptying and release of incretin hormones after glucose ingestion in humans. J Clin Invest. 1996;97:92–103.
15.    Mason EE. Gila Monster’s Guide to Surgery for Obesity and Diabetes. J Am Coll Surg. 2008;206:357–360.
16.    Friedman NM, Sancetta AJ, Magovern GJ. The amelioration of diabetes mellitus following subtotal gastrectomy. Surg Gynecol Obstet. 1955;100:201–204.
17.    Näslund E, Backman L, Holst JJ, et al. Importance of small bowel peptides for the improved glucose metabolism 20 years after jejunoileal bypass for obesity. Obes Surg. 1998;8:253–260.
18.    Mason EE. Ileal transposition and enteroglucagon/GLP-1 in obesity (and diabetic?) surgery. Obes Surg. 1999;9:223–228.
19.    Strader A D, Torsten P V, Ronald JJ, et al. Weight loss through ileal transposition is accompanied by increased ileal hormone secretion and synthesis in rats. Am J Physiol Endocrinol Metab. 2005; 288:E447–E453.
20.    Lu Y, Levin GV, Donner TW Tagatose, a new antidiabetic and obesity control drug. Diabetes Obes Metab. 2008;10:109–134.
21.    Mason EE, Ito C. Gastric bypass in obesity. Surg Clin N Am. 1967; 47:1345–1351.
22.    Wangensteen OH, Wangensteen Sarah D. The Rise of Surgery: From Empiric Craft to Scientific Discipline. University of Minnesota Press, Minneapolis Minn. 1978.
23.    Barris RW, Ingram WR: The effect of experimental hypothalamic lesions upon blood sugar. Am J Physiol. 1936;114:555–561.
24.    Halpern CH, Wolf JA, Bale TL, Stunkard AJ, et al. Brain stimulation in the treatment of obesity. J Neurosurgery. 2008;109:625–634.
25.    Mason EE. Surgical Treatment of Obesity. W.B. Saunders, Philadelphia 1981:403.
26.    Falken Y, Hellstrom PM, Holst JJ, Näslund E. Roux-e-Y gastric bypass surgery for obesity at day three, two months, and one year after surgery: role of gut peptides. J Clin Endocrinol Metab. 2011;96(7):2227–2235.
27.    Koopmans HS, Sclafani A, Fichtner C, et al. The effects of ileal transposition on food intake and body weight loss in VMH-obese rats. Am J Clin Nutr. 1982;35:284–293.
From Bariatric Times:
1.    Mason E. Ed Mason at Large. Bariatric Times. December 2011. Accessed April 27, 2015.
2.    Mason E. Ed Mason at Large. Bariatric Times. January 2012. Accessed April 27, 2015.
3.    Mason E. Ed Mason at Large. Bariatric Times. February 2012. Accessed April 27, 2015.
4.    Mason E. Ed Mason at Large. Bariatric Times. May 2012. Accessed April 27, 2015.
5.    Mason E. Ed Mason at Large. Bariatric Times. July 2012. Accessed April 27, 2015.
6.    Mason E. Ed Mason at Large. Bariatric Times. October 2012. Accessed April 27, 2015.
7.    Mason E. Ed Mason at Large. Bariatric Times. May 2013. Accessed April 27, 2015.

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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