Collected papers of the ACS Metabolic Surgery Symposium Part I

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.

Program speakers

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

Introduction

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.

Vision—A Metabolic Surgery Symposium: Foreword

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.

Metabolic surgery

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.

Metabolic Surgery Symposium attendees: From left, front row: Dr. Hoyt; Dr. Kaplan; Kelvin D. Higa, MD, FACS; David B. Sarwer, PhD; Bruce D. Schirmer, MD, FACS; Natan Zundel, MD, FACS; Raul Jacobo Rosenthal, MD, FACS; Mathias A. L. Fobi, MD, FACS; Dr. Buchwald; Dr. Pories; Daniel M. Herron, MD, FACS; Scott A. Shikora, MD, FACS (slightly behind Dr. Herron); and Jane Buchwald. Middle row (starting behind and to right of Dr. Fobi): John C. Alverdy, MD, FACS; Alan C. Wittgrove, MD, FACS; James W. Maher, MD, FACS: and Hal Sox, MD. Back row: James Mitchell, MD; and (all MD, FACS) Shanu N. Kothari, Michel Gagner, Eric J. DeMaria, John Magaña Morton, Ninh T. Nguyen, Samer G. Mattar, Marc Bessler, and Bruce Wolfe. Not pictured but in attendance: Robin L. Blackstone, MD, FACS, and Stacy Alan Brethauer, MD, FACS.

Invited participants

Organizers

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

Participants

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

Contributors

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

Vision—A Metabolic Surgery Symposium: Foreword (Buchwald and Pories)
Definition and History of Metabolic Surgery (Buchwald et al)
Surgery and the Gordian Knot of the Metabolic Syndrome (Blackstone et al)
Bariatric Metabolic Surgery (Brethauer et al)
Insulin—The Wrong Therapy for Type 2 Diabetes: Lessons Learned from a Half Century of Metabolic Surgery (Pories et al)
Neurologic Metabolic Surgery (Shikora et al)
Bariatric Surgery and Psychiatry (Mitchell et al)
International Variations in Metabolic Surgery (Fobi et al)
Metabolic Surgery in Private Practice (Wittgrove et al)
The Role of the National Institutes of Health in the Development of Metabolic and Bariatric Surgery (Wolfe et al)
Advocacy in Action: Bariatric and Metabolic Surgery (Morton et al)
The American College of Surgeons and Metabolic Surgery (Nguyen et al)
American College of Surgeons Quality and Safety Programs in Metabolic Surgery (Hoyt et al)

Acknowledgments

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.