The History of Metabolic and Bariatric Surgery

The History of Metabolic and Bariatric Surgery

Jordan Robinson and Abdelrahman Nimeri


Often considered a modern problem, obesity has, in fact, powerfully affected the human condition for centuries. With prophetic insight, Hippocrates (460–370 BCE) recognised its impact noting that ‘corpulence is not only a disease itself, but the harbinger of others’. Though detailed knowledge regarding the possible consequences of obesity date back as far as Hippocrates and Galen, the dissemination of this understanding and its transformation into practical and effective intervention took centuries. Consequently, individuals often resorted to extreme measures for treatment. For instance, D. Sancho, king of Leon, lost his throne due to his obesity, in part. After being forcefully escorted to Cordoba at his grandmother’s behest, he was ‘treated’ by Dr. Hasdai Ibn Shaprut who had the kings’ lips sutured together, only allowing a liquid diet consisting of several herbs, including opium.

Shifts in the societal perception of obesity have also taken a protracted course. What was previously considered a characteristic of the affluent was later besmirched. Changes in resource availability, food processing and dietary habits have further transformed our relationship to nutrition and energy.

Today, insights into the pathophysiology of obesity have led to its more recent understanding as a complex and multifactorial disease process. This understanding highlights the importance of metabolic and bariatric surgery (MBS) as the only intervention proven to provide sustained weight loss and reliably led to the remission of otherwise medically refractory metabolic disorders.

The history of MBS mirrors that of scientific inquiry and surgery more broadly (and even the ‘Hero’s journey’, i.e. venturing into the unknown as a prerequisite to profound progress or finding true ‘treasure’). As was aptly noted in The American Society of Metabolic and Bariatric Surgery (ASMBS) Textbook of Bariatric Surgery Volume 1, the greatest achievements of science have often resulted from serendipitous circumstances meeting an adequately prepared and curious mind. Effective solutions to contemporary issues necessitate innovative modes of thinking that are inherently unfamiliar and sometimes contradict previously accepted standards. The consequence is resistance, if not outright ridicule as seen in the preliminary investigation of antisepsis and anaesthesia prior to their acceptance. Surely, enterprising endeavours are not without risk. Investigation into the foundational experiences that have led to modern MBS reflects this reality.

As is the nature of new frontiers, the lack of understanding begets error and error begets doubt, but thoughtful persistence and rigorous course correction can lead to revolutions of understanding and achievement. The story of obesity courses from antiquity to modern times. Despite its protracted historic course, the implementation of effective intervention for obesity has only recently been applied. The history of obesity and its treatment therefore remain in their infancy with MBS representing their essential formative element.

Serendipity and the Origin of Metabolic and Bariatric Surgery

The earliest surgical procedures to produce weight loss with small bowel manipulation or resection were performed by Victor Henrikson (Sweden) in 1952, he noted weight loss after small bowel resection of more than 100 cm of small bowel in a young female. In the same decade in the United States of America, Varco et al. in 1953 performed the first jejunoileal (JI) bypass to treat a lipid disorder. Similarly, and only a year later in 1954, Kremen et al. examined the effects of small intestinal bypass rather than resection in dogs and performed end‐to‐end jejunoileostomy and ileocecectomy, which was the true birth of MBS with the birth of the JI bypass. The first series of JI bypass was performed by Payne et al. in 1963 when he published a series of 10 patients. Another series of JI bypass was performed by Henry Buchwald in 1963 with partial ileal bypass to 100 cm proximal ileocecal valve to treat hyperlipidaemia and obesity. In Europe, Nicola Scopinaro in 1977 performed an intestinal procedure that involved gastric transection as well Biliopancreatic diversion [BPD] with bypass of the intestine 50 cm proximal to the ileocecal valve.

Many patients had JI bypasses before widespread recognition that the procedure carries a significant 50% morbidity and 10% mortality mostly from liver failure, and the JI bypass was abandoned in the USA leaving a stain and a poor image of MBS in the eyes of patients and providers that will take years to erase.

If we consider Nicola Scopinaro, to be the father of MBS in Europe and the founding president of the International Federation for Surgery of Obesity and Metabolic disorders [IFSO], then the father of MBS in the USA is Edward Mason, who is also the founder president of ASMBS. Dr. Mason noticed in the early 1960s that patients undergoing gastric ulcer surgery with gastrectomy and Billroth II gastrojejunostomy for peptic ulcer disease lost weight, and after animal studies, he described in 1967 the gastric bypass in a loop fashion with a horizontal gastroplasty. The original loop gastric bypass underwent several modifications like the original BPD described by Dr. Scopinaro first in a loop fashion. These modifications included converting the loop BPD and loop gastric bypass to Roux‐en‐Y BPD and Roux‐en‐Y gastric bypass (RYGB) due to bile reflux gastritis. The second modification in BPD was to perform an antrectomy to decrease the rate of marginal ulcers, and the second modification in RYGB was to change the transection from horizontal (greater curvature‐based pouch) to a vertical (less curvature‐based pouch) in 1998 by Hess. The final modification in BPD is to perform a sleeve gastrectomy rather than an antrectomy and lengthening the common channel from 50 to 100 cm by Hess and Hess, and the final modification in RYGB is to perform a divided pouch in place of the non‐divided pouch to decrease the incidence of gastro‐gastric fistula.

Dr. Mason is most known for a procedure by his name ‘the Mason procedure’ also known as the vertical banded gastroplasty (VBG), which he first reported in 1973 and would soon become the most performed form of MBS in the 1980s and 1990s before surgeons realised that problematic complications of gastro‐gastric fistula, stenosis at the outlet, gastroesophageal reflux and weight regain. It is important to note that the landmark Swedish Obesity Subject study considered the best non‐randomised prospective observational study ever published in obesity showing that the superiority of surgery to medical therapy is mostly patients undergoing vertical banded gastroplasty, a procedure considered obsolete today.

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May 14, 2023 | Posted by in GENERAL SURGERY | Comments Off on The History of Metabolic and Bariatric Surgery

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