The History of Bariatric Surgery: My Life in Metabolic Surgery

| July 1, 2015

by Henry Buchwald, MD, PhD

Dr. Henry Buchwald is from the University of Minnesota, Minneapolis, Minnesota.

Bariatric Times. 2015;12(7):12–14.

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 helped shape 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


And the Lord God caused a deep sleep to fall upon Adam, and he slept: and he took one of his ribs, and closed up the flesh instead thereof; And the rib which the Lord had taken from man, made he a woman…
Genesis, Book I, Verses 21–22

This biblical depiction of analgesic surgery on a normal structure and wound closure for achievement of an independent purpose may be interpreted to foreshadow metabolic surgery. As incisional, extirpative, and reconstructive surgery came to fruition, several isolated examples of metabolic surgery became embedded in the genealogy of surgery. As early as 1896, regression of breast carcinoma metastases was induced by a bilateral oophorectomy. Most notably, during the late 19th and early 20th centuries, gastric and vagal nerve procedures for peptic, primarily duodenal, ulcer disease were developed. Partial ileal bypass (PIB) for the treatment of hyperlipidemia was introduced between 1962 and 1963, and in 1972 the Program on the Surgical Control of the Hyperlipidemias (POSCH) was initiated with PIB as the intervention modality. POSCH was the first randomized, controlled trial to utilize metabolic surgery. Today, bariatric surgery procedures for weight loss are among the world’s most common operations. These operations exert their potent outcomes via neurohormonal mechanisms rather than by simplistic concepts of food restriction or malabsorption.

In 1978, Richard Varco and I wrote a book titled, Metabolic Surgery.[1] In the Foreward, we defined this discipline of metabolic surgery that encompasses operations on specific, normal anatomic structures to achieve a general, beneficial goal as “the operative manipulation of a normal organ or organ system to achieve a biological result for a potential health gain.” In one way or another, I have spent my professional life in the field of metabolic surgery.

Metabolic surgery procedures have not usually been met with a friendly reception by the academic community. After I completed the basic laboratory and animal research to elucidate the rationale for utilization of the PIB for management of the hyperlipidemias, I performed the first clinical procedure on May 29, 1963. I presented this work and the excellent results we achieved in our first four patients at the American Heart Association meeting in the fall of 1963 in Los Angeles, California. Dr. Louis Katz, a renowned cardiologist and atherosclerosis researcher from Chicago, Illinois, with a reputation for caustic and demeaning commentaries, was in the audience.  When I completed my talk, Dr. Katz rose to his feet and castigated me for several minutes, calling my work unethical and the worst thing he had ever heard since the “Nazi concentration camps.” I defended my work, ending with a comment about Katz’s own research using chickens as human surrogates. A science reporter for the Los Angeles Times heard this exchange, and Katz and I were featured in the paper the next day, under a headline that read, “Chicken Debate at the AHA.” When I informed my legendary chairman at the University of Minnesota, Owen H. Wangensteen, of this event, he smiled and said, “Show me the man who has no enemies, and I will show you the man who has done nothing.”

My introduction into the field of metabolic/bariatric surgery came during my chief residency at the University of Minnesota. My mentor, Dr. Richard L. Varco, has been credited with performing the first bariatric procedure in 1953, a jejunoileal bypass. He recognized the need for the propagation of bariatric surgery in 1966. Unfortunately, at that time, he had injured the median nerve in his right forearm and was experiencing an arduous recovery period. He asked me to start a series of jejunoileal bypass operations. I refused, saying that I did not wish my work with PIB for nonobese, hyperlipidemic patients to be confused with jejunoileal bypass for patients with obesity. One day, after he had a fresh cast applied to his arm, we met in the hallway. He emphatically waved his arm at me and said, “I would take this project on if I could operate. You can operate, and you refuse to do it.” I immediately agreed. Over the past 50 years, I have never regretted this decision. I soon recognized that obesity was a disease that should be treated as such, and that the unfortunate victims of this terrible affliction with its myriad of comorbidities deserved not only our empathy, but also our help as physicians and our skills as surgeons.

I have been privileged to know some of the original pioneers of metabolic/bariatric surgery: Ed Mason, H. William Scott, Nicola Scopinaro, Walter Pories, George Cowan, and, over the years, hundreds of other surgeons who have contributed to the growth and understanding of this specialty. I have chronicled its development. In 2002, Jane Buchwald and I wrote a brief history of the evolution of bariatric surgery,[2] and I returned to this topic in 2014.[3] I have been a witness to the origins of cardiac, transplantation, and replacement surgery, all of which faced skepticism at first but were rapidly not only accepted but exalted. Not so for bariatric surgery. Though in the not too distant future it is predicted that over 50 percent of Americans will be obese, the obese continue to be treated with disdain.  When I began, I was told by good friends that my involvement with bariatric surgery would cost me my career. All of us in this field, from early advocates to recent practitioners, have been and continue to be subjected to the consequences of this prejudice.

I have recommended that the operative practice of bariatric surgery is for outstanding technical surgeons who can perform difficult operations safely with an absolute minimal operative mortality. Further, I believe that in addition to their technical skills, metabolic/bariatric surgeons should strive to be cognitive contributors in the quest to elucidate what bodily mechanisms our operations affect, and how these outcomes impact the metabolic processes of obesity and its comorbidities.

I have been an advocate of meta-analysis for its power to combine the outcomes of various trials and studies by use of rigid statistical precepts. In 2004, I published with my coauthors a meta-analysis that has been one of the most cited papers in the metabolic/bariatric literature. This paper confirmed the affirmative impact of various metabolic/bariatric procedures in the mitigation of type 2 diabetes mellitus (T2DM), hypertension, hyperlipidemia, and obstructive sleep apnea.[4] I have coauthored three subsequent meta-analyses on metabolic/bariatric surgery mortality,[5] the operative impact limited to type 2 diabetes,[6] and the utility of the banded gastric bypass.[7]

With Dr. Stanley Williams, and my assistant of 35 years, Danette Oien, I have carried on the project initiated by Scopinaro in 1998 to chronolog the prevalence and distribution of metabolic/bariatric surgery worldwide using the databases of the nations represented in the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO).[8–10] This task has now been assumed by IFSO during Dr. Luigi Agrisani’s presidency.[11] Together with the economist Pierre-Yves Cremieux, I have also analyzed the economic impact of bariatric surgery.[12]

While President of the American Society for Bariatric Surgery (ASBS) and IFSO, I worked to bring these two bodies into closer union and to promote ties to nonsurgical obesity management organizations. In my long participation in the governance of these societies, I have espoused the principle that bariatric surgery is metabolic surgery, and that we must look to our procedures as eliciting metabolic goals, particularly in the management of T2DM. In 2007, the word “Metabolic” was added to the ASBS name, and IFSO added “and Metabolic Disorders” to its official designation.

I hold a dual appointment at the University of Minnesota as Professor of Biomedical Engineering, in a department dedicated to device innovations and cooperative ventures with the medical sciences. In my laboratory, the first implantable infusion pump was developed. We designed two mechanical versions, one driven by a chemical power source, the other by a spring mechanism. Most of the applications we envisioned for this device involved the infusion of therapeutic agents (e.g., intravenous heparin, intrathecal analgesics and antispasmodics) and hepatic artery chemotherapeutic drugs. One use, however, was metabolic in nature: continuous, intravenous, insulin infusion in type 2 diabetics.[13] In the future, ours and similar devices will be used to infuse incretins and other substances to influence the metabolics of obesity, diabetes, and other diseases.
Occasionally one’s work comes full cycle. The POSCH trial was the first affirmative lipid/atherosclerosis trial and the one with the longest follow-up (over 25 years). It definitively demonstrated that the lipid modification and/or other metabolic processes induced by PIB surgery caused statistically significant decreases in overall mortality, recurrent myocardial infarctions, peripheral vascular disease, the incidence of coronary artery surgery and angioplasty, and progression (actual regression demonstrated) of coronary artery disease on sequential arteriography, as well as an increase in life expectancy.[14–17] Most recently, a re-examination of the POSCH data has shown a 2.6-fold increase in the incidence of T2DM in the control group in comparison to the PIB intervention group after greater than 30 years; both populations having been free of diabetes at the onset of the trial.[18] Exploration of the diabetes-protective effect of PIB has brought me back to my own roots in metabolic surgery.

Let me close with an appraisal of the status of metabolic/bariatric surgery 60 years after its origin. While it is flourishing in Europe and is ascending in India, China, the Mediterranean basin, the Far East, and in Central and South America, it appears to be dwindling in the United States. Conceptual recognition from the National Institutes of Health (NIH) is absent. Lack of critical financial support by the Affordable Care Act[19] has been a powerful deterrent; 28 states do not mandate paying for metabolic/bariatric procedures. Some payers limit or deny access for metabolic/bariatric surgery. Also, certain departments of surgery, even in academic institutions, seek to minimize or eliminate metabolic/bariatric surgery, revisional procedures in particular. If we can ascribe one underlying cause for this decline, it is the shift in decision-making and control from clinicians to various administrative bodies.[20,21] We need to consider how to reverse this erosion of our responsibilities. I believe it is the moral obligation of all medical practitioners to protect the right of those unfortunately afflicted by a disease, including obesity, to receive treatment.

Thoughts for Reflection
Pharmaceuticals stimulate, block, or replace bodily processes. Metabolic surgery opens individual pathways of automedication by induced neurohormonal mechanisms. Metabolic surgery is a reality—a major modality combining thought and intervention. Bariatric surgery is the standard bearer for the discipline of metabolic surgery.

References
1.    Buchwald H, Varco RL, eds. Metabolic Surgery. New York, Grune & Stratton, 1978.
2.    Buchwald H, Buchwald JN. Evolution of operative procedures for the management of morbid obesity 1950–2000. Obes Surg 2002;12:705–717.
3.    Buchwald H. The evolution of metabolic/bariatric surgery. Obes Surg. 2014;24:1126–35.
4.    Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004;292(14):1724–1737.
5.    Buchwald H, Estok R, Fahrbach K, Banel D, Sledge I. Trends in mortality in bariatric surgery: a systematic review and meta-analysis. Surgery. 2007;142(4):621–632; discussion 632–635.
6.    Buchwald H, Estok R, Fahrbach K, et al. Weight and type 2 diabetes after bariatric surgery: systematic review and meta-analysis. Am J Med. 2009;122(3):248–256.e5.
7.    Buchwald H, Buchwald JN, McGlennon TW. Systematic review and meta-analysis of medium-term outcomes after banded Roux-en-Y gastric bypass. Obes Surg. 2014;24(9):1536–1551.
8.    Buchwald H, Williams SE. Bariatric surgery worldwide 2003. Obes Surg. 2004;14:1157–1164.
9.    Buchwald H, Oien DM. Metabolic/bariatric surgery Worldwide 2008. Obes Surg. 2009;19:1605–1611.
10.    Buchwald H, Oien DM. Metabolic/bariatric surgery worldwide 2011. Obes Surg. 2013;23:427–436.
11.    Angrisani L, Santonicola A, Iovino P, et al. Bariatric Surgery Worldwide 2013. Obes Surg. 2015 Apr 4. [Epub ahead of print]
12.    Cremieux PY, Buchwald H, Shikora SA, et al. Am J Manag Care. 2008;14:589–596
13.    Rupp WM, Barbosa JJ, Blackshear PJ, et al. The use of an implantable insulin pump in the treatment of type II diabetes. N Engl J Med. 1982;307(5):265–270.
14.    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(14):946–955.
15.    Buchwald H, Matts JP, Fitch LL, et al. Changes in sequential coronary arteriograms and subsequent coronary events. Surgical Control of the Hyperlipidemias (POSCH) Group. JAMA. 1992;268(11):1429–1433.
16.    Buchwald H, Varco RL, Boen JR, et al. Effective lipid modification by partial ileal bypass reduced long-term coronary heart disease mortality and morbidity: five-year posttrial follow-up report from the POSCH. Program on the Surgical Control of the Hyperlipidemias. Arch Intern Med. 1998;158(11):1253–1261.

17.    Buchwald H, Rudser KD, Williams SE, et al. Overall mortality, incremental life expectancy, and cause of death at 25 years in the program on the surgical control of the hyperlipidemias. Ann Surg. 2010;251(6):1034–1040.
18.    Obes Surg. 2015. submitted for publication.
19.    U. S. Department of Health and Human Services. About The Affordable Care Act. http://www.hhs.gov/healthcare/rights/ Accessed June 15, 2015.
20.    Buchwald H. Presidential address: a clash of cultures-personal autonomy versus corporate bondage. Surgery. 1998;124(4):595–603.
21.    Buchwald H. The problem of self-determination of professionalism and ethics. Bull Am Coll Surg. 2009;94(4):8–13.

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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