Ed Mason at Large

This ongoing column is dedicated to sharing with readers the life and experiences of Dr. Edward Mason.

A Message from Column Editor
Tracy Martinez, RN, BSN, CBN

Happy New Year to all! We are once again delighted to “bring” Dr. Ed Mason to you. This interactive column has already stimulated many positive comments. I hope you will participate in dialogue by submitting questions so we can all enrich our professional knowledge and understand the roots of our specialty.

“The teacher who is indeed wise does not bid you to enter the house of his wisdom but rather leads you to the threshold of your mind.” -Kahlil Gibran

Sincerely,

Tracy Martinez, RN, BSN, CBN
Program Director
Wittgrove Bariatric Center
La Jolla, California

We are aware of the type 2 diabetes (T2D) “epidemic” as well as the staggering costs and associated medical complications of this disease. Why do you think there is such reluctance for primary care physicians to refer patients for bariatric surgery who are diagnosed with T2D and morbid obesity? What can be done to increase access—education, more clinical studies?

-Tracy Martinez, RN, BSN, CBN

Dr. Mason: Treatment with either the outdated intestinal or gastric bypass results in hypertonic contents reaching the jejunum where they stimulate an osmotic catharsis sufficient to expose the distal bowel to glucose, bile salts, and other stimulants of the L cells to secrete glucagon-like peptide- 1(GLP-1). There is no indication to refer a patient for surgical treatment of T2D if the body mass index (BMI) is less than 40kg/m2 even though bypass surgery would be effective. That is because there are GLP-1 mimetics available for treating type-2 diabetes and should be used before considering surgery. If diabetes is not eliminated by GLP- 1 mimetics or surgery, then it is probably not type 2 and an endocrinologist is needed. With BMI above 40kg/m2, surgery is still available with or without diabetes.

As you see the American Society for Metabolic and Bariatric Surgery (ASMBS) increase in membership, fellowship programs, Centers of Excellence (COE) with the American College of Surgeons (ACS) and Surgical Review Corporation (SRC), what are your thoughts about the growth and development? Do you see common efforts on which we should work collectively to increase awareness and access, training?

-Tracy Martinez, RN, BSN, CBN

Dr. Mason: Such creative, pertinent growth and cooperation is exciting, especially at this time when our democratic government cannot function.

Dr. Mason, Thank you for taking time to reach out to us through your column. You developed the gastric bypass as well as gastroplasty. What are your thoughts or perils about these procedures? Particularly, what are the most important technical aspects of the procedures? What parts of the operations do you think need the most attention to surgical detail? Additionally, do you think there are assistants yet to be developed that will help perform the gastric bypass more precisely, such as a biomarker that will show where the Ghrelin cells are located or a marker that will show us the best place for the creation of the enteroenterostomy?

-Alan Wittgrove, MD, FASMBS
Medical Director, Wittgrove Bariatric
Center, La Jolla, California

Dr. Mason: In the 21 years since I retired, there have been remarkable changes in the performance of obesity surgery thanks to you and the many who are participating in a healthy changing paradigm. I never performed any minimally invasive surgery. I remember when we began to receive equipment made specifically for the operations and how much easier it was. The operations took as long as six hours
in the beginning. There was room for only one hand to tie a knot in an anastomosis. My mentor Owen H. Wangensteen split the lower sternum in order to perform near total gastrectomy. With recorded pouch volumes at the initial operation and again at the time of revision, we learned how much the pouch could enlarge if it was too large after the initial operation. We also learned that the pouch outlet should be 11mm in diameter. There is evidence in the Swedish Obesity Subjects (SOS) that the adjustable gastric band does not provide as much weight loss as a properly sized vertical banded gastroplasty.[1] I don’t believe it is necessary to identify the location of Ghrelin cells if the angle of His is used as the site of the upper end of a vertical staple line. Maybe there are reasons why a vertical staple line is no longer practical.

Dr. Mason, as a corollary to Dr. Wittgrove’s questions, in light of the metabolic/hormonal changes demonstrated in bypass or resectional procedures, is there still a place for purely “restrictive” operations such as the vertical banded gastroplasty, laparoscopic adjustable gastric band, or even the plication?

-Kelvin Higa, MD, FACS
Clinical Professor of Surgery, University of California, San Francisco, Fresno, California, and Director, Minimally Invasive and Bariatric Surgery, Fresno Heart and Surgical Hospital, Fresno, California

Dr. Mason: I think we should have a vertical gastroplasty like VBG but with a minimum of foreign material. Andrew C. Jamieson[2] used such an operation for a lifetime of obesity surgery. Unfortunately, vertical banded gastroplasty (VBG) and laparoscopic adjustable gastric banding (LAGB) were sufficiently popular that Jamieson’s modification of the Michael Long gastroplasty[3] never received the attention required for establishment of an alternative. The operation deserves further study with minimally invasive surgery.

Plication was studied in dogs and humans by Tretbar[4] in Kansas City. The weight loss at 6 and 12 months following surgery was half of what we observed after gastric bypass. The plication, with two rows of sutures, unfolded. Tretbar decided that a long lesser curvature gastroplasty without any reinforcement of the outlet would provide what plication had failed to provide. Wilkinson[5] wrapped the stomach plication with cloth, which prevented unwrapping. I do not know the composition of the “cloth,” but it caused adhesions. These efforts were reported at our annual Iowa City Workshops, which began in 1976. As for the metabolic/hormonal changes, restriction operations do not cause hypertonic contents to reach the jejunum. There is no flush and no secretion of GLP-1. Therefore, they resolve T2D only to the extent that they reduce food intake and are effective in reducing weight. In retrospect, Billroth II gastrectomy since 1885 has prevented and cured T2D with dumping. We finally recognized the mechanism in 1998. What we must do now is spread the knowledge provided by J. J. Holst and many others[6] about GLP-1 and the need for low-cost glucose mimetics that can be provided for a billion people who either have T2D or have levels of glucose and insulin that can cause irreversible complications even before a diagnosis of diabetes is made.

REFERENCES
1.    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.
2.    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.
3.    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.
4.    Tretbar LL,Taylor TT, Sifers EC. Weight reduction, gastric plication for morbid obesity. J Kansas Medical Society. 1976;77:488.
5.    Curley SA, Weaver W, Wilkinson LH, Demarest GB. Late complications after gastric reservoir reduction with external wrap. Arch Surg. 1987;122:781–783.
6.    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.

Category: Ed Mason at Large, Past Articles