December 4, 2018
Editor’s note: The Bulletin will be publishing the collected papers from the Metabolic Surgery Symposium, which took place in August 2017 at the American College of Surgeons (ACS) headquarters, Chicago, IL. These papers will be published starting in January 2019. To kick off the series, the following pages include introductory remarks from symposium co-chairs Henry Buchwald, MD, PhD, FACS, and Walter J. Pories, MD, FACS; a preface; a list of invited participants; and the table of contents. Be sure to read the January issue for papers on the definition and history of metabolic surgery and efforts to untangle the “Gordian knot” of metabolic syndrome.
Definition and History of Metabolic Surgery
Henry Buchwald, MD, PhD, FACS
Bariatric Metabolic Surgery
Stacy A. Brethauer, MD, FACS
Mechanisms of Metabolic Bariatric Surgery
Lee M. Kaplan, MD, PhD, FACS
Diabetes Metabolic Surgery
Walter J. Pories, MD, FACS
Neurologic Metabolic Surgery
Scott A. Shikora, MD, FACS
Psychiatry and Metabolic Surgery
James Mitchell, MD
International Metabolic Surgery
Mathias A. L. Fobi, MD, FACS
Metabolic Surgery in Private Practice
Alan C. Wittgrove, MD, FACS
ACS Quality and Safety Programs in Metabolic Surgery
David B. Hoyt, MD, FACS
The NIH Perspective on Metabolic Surgery
Bruce M. Wolfe, MD, FACS
Advocacy in Metabolic and Bariatric Surgery
John Morton, MD, MPH, FACS
The ACS and Metabolic Surgery Group
Ninh T. Nguyen, MD, FACS
As recently as 50 years ago, surgery was a single craft and branch of knowledge. Most surgeons were general surgeons. With the advent of specialization, two distinct surgical disciplines emerged—those specialties dedicated to an organ or organ system (for example, cardiovascular and colorectal) and those concerned with a specific function or activity (such as trauma, plastic, and reconstructive). Bridging these concepts, metabolic surgery conceptualizes a new scope of practice. As a rule, metabolic surgeons operate on a variety of normal, rather than diseased or malfunctioning, organs to alter the body’s metabolism to benefit the patient. Metabolic surgery, therefore, comprises a variety of operations and the scientific study of their outcomes in order to ameliorate metabolic diseases. The flagship of metabolic surgery today is bariatric surgery; however, metabolic surgery also encompasses operations that control or eliminate diabetes or hypertension and that regulate brain chemistry, and its ramifications are expanding.
by Henry Buchwald, MD, PhD, FACS, and Walter J. Pories, MD, FACS
The ACS recognized the discipline of metabolic surgery and its clinical, research, and educational potential by sponsoring the August 9–10, 2017, Metabolic Surgery Symposium. The written record of this forum will be serialized in the Bulletin over the next six months. This symposium is dedicated to ACS Executive Director David B. Hoyt, MD, FACS, who has the vision to appreciate the metabolic surgical efforts of the present and their promise for the future.
On August 9–10, 2017, a conclave of surgeons and internists gathered for the Metabolic Surgery Symposium under the sponsorship of the ACS. The 12 papers presented and subsequent discussions are summarized in this composite review. This symposium offers insights into the definition and history of metabolic surgery, applications of its principles in the management of obesity, type 2 diabetes, and psychological problems, and the ramifications of this discipline internationally, in private practice, in outcomes assessment, and within the purview of the National Institutes of Health (NIH) and the ACS. Uniquely, each of the speakers and commentators was heard and their perspectives recorded.
The discipline of achieving a metabolic goal by operating on normal organs, that is, metabolic surgery, is expanding in contrast to the traditional elective surgical endeavors of incisional, extirpative, and reparative surgery. The availability of a wide spectrum of antibiotics and, even more so, of fluoroscopic or computed tomography (CT)-guided drainage procedures performed by interventional radiologists has made incisional surgery, for the most part, unnecessary. The era of massive excisional or extirpative surgery for malignancies, with its challenges of dissection and reconstruction, has given way to limited resections as part of a therapeutic constellation of chemotherapy and external beam or implant radiotherapy. Reparative surgery has become dominated by prosthetic replacements—often performed using limited operations—and transvascular access procedures. The specialty of plastic surgery for congenital malformations and the demand for cosmetic surgery are limited to a small cadre of the surgical profession. And the once-burgeoning field of organ transplantation is slowly yielding to immune-free cell cloning and implantation.
Technologic progress allows for greater manual capability and thereby expands the horizons of surgery. Open surgery has yielded to laparoscopic, thoracoscopic, and other minimally invasive surgical techniques and may soon succumb to robotic surgery. Endoscopic surgery will dominate gastrointestinal surgery, and surgery-capable instrumentation will become available to traverse the entire gut. Natural orifice transluminal endoscopic surgery (also known as NOTES) and surgery via a minimal neo-orifice will encompass routine procedures.
Enhanced technological capability, however, is not equivalent to intellectual growth. Our expanding tool kit can open new vistas, but we require ongoing original thought to take advantage of the opportunities open to us for exploration. Surgeons have to expand the organ-specific concept of disease of the 19th and 20th centuries to encompass the holistic philosophy that illness, disease, medicine, and cure are governed by complex interrelated processes and that this mosaic of causation and resolution is regulated by metabolic mechanisms. Today, therefore, we recognize that body metabolism out of balance results in disease, and we are starting to appreciate that we, as surgeons, in practicing metabolic surgery, have the ability to resolve some of these metabolic imbalances and thereby restore good health to our patients.
Recently, a complex of diseases has been termed the metabolic syndrome, consisting primarily of dyslipidemia, hypertension, type 2 diabetes, and obesity. Internal medicine treats this syndrome by separating its constituents into independent entities for management with pharmaceuticals and lifestyle modifications—all palliative, resulting in low success rates, and required for the lifetime of the patient. Metabolic-bariatric surgery can treat the entire syndrome with a single operation, which may offer lifelong resolution or amelioration of each of its elements.
In the future, care for the multiple human illnesses of metabolism gone wrong may well involve a metabolic algorithm such as the following: metabolic problem, metabolic assessment trial of nonsurgical options of therapy, and, if these approaches prove unsuccessful, synergistic nonsurgical and metabolic surgical management or metabolic surgery alone.
The compilation of topics of this proceeding is an invitation to our fellow surgeons, our fellow health care professionals, our leaders of industry, our politicians, and, above all, our patients to join the symposium participants in the promotion of the vision of metabolic surgery.
David B. Hoyt, MD, FACS Executive Director, ACS
Henry Buchwald, MD, PhD, FACS Symposium Chair University of Minnesota Medical School, Minneapolis
Walter J. Pories, MD, FACS Symposium Chair Brody School of Medicine, East Carolina University, Greenville, NC
David B. Hoyt, MD, FACS,
Henry Buchwald, MD, PhD, FACS
Walter J. Pories, MD, FACS
John Alverdy, MD, FACS University of Chicago, IL
Marc Bessler, MD, FACS Columbia University, New York, NY
Robin Blackstone, MD, FACS Banner University Medical Center, Phoenix, AZ
Stacy Brethauer, MD, FACS Cleveland Clinic, OH
Eric DeMaria, MD, FACS East Carolina University, NC
Mathias Fobi, MD, FACS Sri Aurobindo Medical College, Indore, India
Michel Gagner, MD, FACS Hôpital du Sacré-Coeur de Montréal, QC
Dan Herron, MD, FACS Mount Sinai Hospital, New York, NY
Kelvin Higa, MD, FACS Fresno Bariatrics, CA
Lee Kaplan, MD, PhD, FACS Massachusetts General Hospital, Boston
Shanu Kothari, MD, FACS Gundersen Health System, La Crosse, WI
James Maher, MD, FACS Virginia Commonwealth University School of Medicine, Richmond
|Samer Mattar, MD, FACS Oregon Health & Science University, Portland James Mitchell, MD, FACS University of North Dakota School of Medicine and Health Sciences, Fargo John Morton, MD, MPH, FACS Stanford University, CA Ninh Nguyen, MD, FACS University of California, Irvine
Raul Rosenthal, MD, FACS Cleveland Clinic, Weston, FL
David Sarwer, PhD College of Public Health at Temple University, Philadelphia, PA
Scott Shikora, MD, FACS Brigham and Women’s Hospital, Boston
Bruce Schirmer, MD, FACS University of Virginia, Charlottesville
Harold Sox, MD Patient-Centered Outcomes Research Institute, Bethesda, MD
Alan Wittgrove, MD, FACS Scripps Memorial Hospital, La Jolla, CA
Bruce Wolfe, MD, FACS Oregon Health & Science University
Natan Zundel, MD, FACS Herbert Wertheim School of Medicine, Florida International University, Miami
Jane N. Buchwald Chief scientific research writer, Medwrite Medical Communications
Georgeann Mallory Executive director, ASMBS
Patrick Beebe Executive Assistant, ACS
Donna Coulombe Executive Assistant, ACS
Table of contents
This work was supported by the ACS. The authors declare that they have no relevant conflict of interest.
We are grateful to the ACS for their generous sponsorship of the Metabolic Surgery Symposium and associated journal publication development. We thank Jane N. Buchwald, chief scientific research writer, Medwrite Medical Communications, WI, for manuscript editing and publication coordination. And we thank Patrick Beebe and Donna Coulombe, ACS, for their expert organization of the Metabolic Surgery Symposium.