I was deeply honored when asked to write the foreword for this wonderful tome entitled, Laparoscopic Bariatric Surgery: Techniques and Outcomes. But as the glow washed over me, I immediately became concerned because of the implications of such a request. Forewords are usually either added on as an afterthought or delegated to some curmudgeon whose era of influence has passed. Either way the ego, though stroked, also becomes somewhat exposed.
As I reflect over my career in general academic surgery, I am deeply impressed with the advances that surgery has made in the treatment of individuals with serious obesity. Bariatric surgery in the beginning was at best a novelty and, in most inner circles of medicine, was condemned. Surely this condition (certainly not a disease) was simply a lack of willpower on the part of the patients so afflicted and certainly did not fall within the realm of "respectable" surgery. These patients deserved their fate because of their lack of self-control. This situation was the end result of gluttony and sloth and, if these patients had but a modicum of wit about them, they would not allow themselves to get into such "shape."
One only has to go back and look at the original publications by Payne, DeWind, and Commons to appreciate something entirely different. These California-based physicians (only one was a surgeon) saw serious obesity as a morbid condition. Not only were patients incapacitated by their excessive body weight, but they clearly identified obesity as a disease and its causal relationship with other disease states. Their publication in 1963 was, however, not the first publication related to operations for serious obesity. In the early fifties, Kremen, Linner, and Nelson at Minnesota and as a part of their work on the absorptive aspects of the jejunum and ileum, described a 385 pound patient in whom an intestinal bypass was performed. These observations were presented to the American Surgical Association Meeting in April, 1954 and, in his discussion of this paper, Philip Sandblom alluded to the fact that two years earlier Dr. Viktor Hendriksson of Sweden had performed a similar procedure on a morbidly obese patient in his homeland. Sandblom stated that the procedure had produced weight loss but that it had "created a difficult situation of nutritional balance."
Apparently, Payne, DeWind, and Commons were either aware of this previous publication or were deeply concerned about the metabolic consequences of short circuiting the intestine to the degree that they proposed. In their work they describe an extremely elaborate protocol that attempted to measure, albeit in a static state, the changes that might occur during the postoperative period. In their initial group of patients, after weight loss had occurred, they re-operated on these patients and placed their gastrointestinal tract back in continuity. They quickly learned that all of the patients so reconstructed gained back their previous weight. This greatly perplexed them. In the final three patients, they either modified the shunt or left it intact. It should be noted that only one patient in this series died and that death was apparently related to a pulmonary embolism in the late postoperative period (about six months).
It is not the intent of this discussion to outline the history of the development of bariatric surgery. Suffice it to say that a number of surgeons modified the jejunoileal bypass during the next two decades, while another cohort of surgeons attacked the problem from the other end of the gastrointestinal tract. This upstart contingency was led by Ed Mason at the University of Iowa who had actually begun his work while at Minnesota as a resident. He proposed restricting food intake by performing a procedure on the stomach that limited its reservoir capacity and shunted food into the jejunum, therefore bypassing the distal stomach, duodenum, and the most proximal jejunum. By the late 1970s, Mason had gathered together a small enclave of surgeons interested in the problem of morbid obesity. They met during June in Iowa City to discuss the developing expertise in this area. It was from this nidus that the American Society for Bariatric Surgery (ASBS) had its origins. The group was formally incorporated in the early 80s with a membership of less than 200. At the most recent annual meeting of the ASBS in excess of 1100 physicians, surgeons, and ancillary health care providers attended.
By the mid 1970s, the literature began to reflect a number of complications for the intestinal bypass procedures. Some of these were merely worrisome while others were death rendering. Concurrent to this obvious concern were benefits such as a much better understanding of the disease state of obesity, its metabolic implications, the natural history of the disease, its genetic implications, and the effects that weight loss produces on the co-morbid conditions associated with excess body weight. Surgeons also learned much about the management of seriously obese individuals who require an abdominal procedure for other causes.
Despite all of these activities, the legitimacy of surgical intervention for morbid obesity was still questioned by most of the medical community. Somehow, physicians in all specialties just couldn't accept the concept ofsuch a major operation being performed in patients to help control excess body weight.
And then along came laparoscopic procedures. At first, approaching the abdominal cavity through a port with long instruments and a television camera just didn't seem to be true surgery. A number of individuals who were clearly leaders of surgery spoke out vehemently against the travesty of converting a relatively easy and commonly done procedure to remove the gallbladder into a video game with no one a clear cut winner. They decried the length of time the procedure took and the unacceptably high incidence of injured to adjacent organs. The parochial wisdom of surgeons stayed the course of this imaginative intervention for only a very short while. Patients considered themselves the winner. They could have such a procedure performed and found themselves shed of their diseased gallbladder with relatively little discomfort and the ability to return to work within four or five days. Patients drove the acceptance of the process and it became accepted in a very short while. In fact, if the laparoscopic approach to the procedure was not offered, most patients frequently sought another surgeon.
At this point, surgeons discovered that they can do more than remove the gallbladder using this technology. Multiple innovative techniques blossomed. Instruments improved, and finally, one daring individual decided that they would try to perform some type of gastric restrictive procedure through the scopes. At this point, as my old Irish grandmother was fond of saying, "Katie, bar the door!"
The laparoscopic gastric bypass, though performed by many early in the course, was probably brought to most surgeons' attention by Clark and Whitgrove, again from California. This operation became the tour-de-force of every laparoscopic surgeon in America and, perhaps, the world. When they had accomplished everything else, they knew they had arrived on the laparoscopic scene, if they could perform the laparoscopic gastric bypass in a patient over 325 pounds in less than five hours. In fact, many surgeons now have gotten this procedure down so that heavier patients are being operated upon with an average time of less than three hours. The patients often are discharged on postoperative day two. It has truly been miraculous!
The upside is that the technical achievements are consistent with the surgeon's abilities and the fact that, if individuals who pursue surgery as a career or challenge technically, they will rise to the occasion and accomplish many of the important adjustments necessary to reach such limits of brilliance are included in this tome. However, the downside is that patients with this disease process are not simply mannequins to test one's technical abilities. They are patients with a complex disease process, and the operations that we perform produce a state of metabolic jeopardy that must be managed over a protracted period of time. In the beginning, surgeons took on the commitment of follow-up for the patient's life span. I do not see any reason to abandon that initial tenet at this stage. Simply because we can do the operations with greater facility and have patients out of the hospital quicker does not mean that the procedure has any less risk in the late postoperative period. Patients are still at risk for metabolic derangement years after the procedure and need to be followed, not only for such abnormalities.
We must also use ancillary healthcare professionals to support patient's psychiatric adjustment to their new-found involvement in society.
Morbid obesity is a serious disease that is multifactorial. It produces a state of social maladaptation, compromised socioeconomic state, and a vulnerability that is infrequently recognized. Patients operated upon experience enormous changes in their life, as well as in their metabolic state and need to be followed for a protracted period of time. This tome deals in great detail with the procedures and approach to morbidly obese patients. It will be a great asset to all surgeons involved in the care of these patients. However, technical success, if not coupled with care of the total patient, is a hollow victory.
The Isidore Cohn, Jr. Professor and Chairman of Surgery LSU Health Sciences Center New Orleans, Louisiana, U.S.A.
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