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Surgery for Obesity and Related Diseases 11 (2015) 286–287

ASMBS Executive Committee interview of Dr. Mason

Keep it simple, surgeon

“How did you become interested in bariatric surgery?”

My research interest in 1965 was not obesity, but todesign a simple and reversible operation to replace gastricresection. My sudden interest in obesity in 1966 was for adisease to treat with gastric bypass. In 1966, after showingin the laboratory that gastric bypass would decrease thesecretion of hydrochloric acid and not cause ulcers, I began2 studies in patients. In 1 study of 8 patients with duodenalulcer, only 1 was cured. He was also morbidly obese andlost a significant amount of excess weight. A simultaneoussecond study of using a loop gastric bypass to treat morbidobesity was more successful, as you know.

“How did you know that a loop bypass would lead to adesirable weight loss procedure?”

Many patients with peptic ulcer, treated with subtotalgastrectomy and a loop gastroenterostomy lost weight, evenwhen they had a normal weight. They learned to eat smallermeals more frequently and to avoid fattening foods thatcaused dumping symptoms. Gastric bypass made a virtueout of milder dumping, which for lean patients with ulcerhad been an undesirable, weight-losing side effect. Mymentor, Owen H. Wangensteen, told patients they wouldlive longer at a lower weight.

“What drove you to organize the ASBS and ASBSR?”

I had been considering establishing an American Societyfor Bariatric Surgery, because I had hosted an obesitysurgery postgraduate course, the University of Iowa ObesitySurgery Colloquium, for 7 years beginning in 1977. Wewere obesity surgeons and physicians teaching each other.We knew gastric bypass was curing diabetes in 1977, just ashad been observed following the introduction of intestinalbypass in 1953. No obesity surgeon could fail to thinkabout such a benefit. The mechanism finally becameevident. The common denominator between intestinal andgastric bypass in resolving type 2 diabetes mellitus (T2DM)was endogenous GLP-1 secretion by L-cells as a result ofshort-circuiting the intestine and with dumping symptoms.

/10.1016/j.soard.2015.01.00815 American Society for Metabolic and Bariatric Surgery. All r

Glucose and other stimulants reached the L-cells beforethey could be absorbed.The American Society for Bariatric Surgery Registry

(ASBSR) was begun in 1985. It was voluntary and providedfor surgeons who wished to achieve continuous improve-ment in patient care. William Edwards Deming’s earlyfailure in the United States and success in Japan with the“Statistical Product Quality Administration,” which isthought to have been the system that was responsible forthe postwar Japanese “miracle” [1], was a stimulus to createthe ASBSR.

“What do you envision the future of bariatric surgerywill be?”

Sleeve gastrectomy is becoming the current operation ofchoice. Unfortunately, sleeve gastrectomy is more complexand irreversible. Epidemics of obesity and type 2 diabeteshave spread to adolescents and children. Fortunately, Elias[3], and co-workers [2,3] have shown in rodent and growingporcine models that the ballooning portion of the stomachcan be invaginated rather than resected [2,3].The invaginated fundus is anastomosed internally to the

antrum, Fundic invagination could be called a sleevegastrotomy, since it is to sleeve gastrectomy as gastricbypass is to gastric resection. My goal for gastric bypasswas to “Keep it simple, surgeon” and be reversible. Ienvision sleeve gastrotomy as the operation of choice for allages and times. However, this procedure has not yet beenevaluated in humans. There have been a number of studies,mostly from Iran, evaluating a gastric plication that mayalso be a reversible weight loss procedure; however, long-term evaluation of this procedure is still needed [4].Lifelong follow-up is a goal that remains to be met for all

operations for obesity and T2DM. This will be addressed asphysicians, patients, and the curious learn about dumpingfor T2DM and stimulation of GLP-1 secretion. Recordkeeping is no longer optional. You will learn how to makescientific use of these data while preserving patient privacy.This will require permission of the patient and participationwith special protection, perhaps for lifelong prospectiveresearch. As always, prospective studies based upon

ights reserved.

Editorial / Surgery for Obesity and Related Diseases 11 (2015) 286–287 287

hypotheses will require collection of pertinent data. Thesedata may change with increasing knowledge of mechanismsand consequences. You will explain to patients the normaland therapeutic importance of dumping for stimulation ofGLP-1 secretion. You will explore and explain resolution ofT2DM with glucose mimetics that are poorly absorbed andresolve T2DM when obesity is not a concern. The surgicalviewpoint will help resolve the obesity and T2DM epi-demics in adults, adolescents, and children. You willunderstand why only type 1 diabetes is insulin dependent.T2DM is GLP-1 and dumping dependent. Some patientswith T2DM develop type 1 diabetes, and will then needtreatment for both types 1 and 2. This meeting is animportant step toward agreeable, science- supported view-points and optimal patient care. Severe obesity and T2DMwill, perhaps, be treated with surgery without stomachresection if fundic invagination (sleeve gastrotomy)becomes the standard of care. Further scientific laboratoryand translational clinical study is urgent and will beongoing to save kidneys and eyes, limbs and lives.The future is based upon the past. The elimination of

need for treatment of T2DM after gastric bypass wasreported at the first University of Iowa Obesity SurgeryColloquium in 1977. You will know how hyperosmoticflushing (also known as dumping) exposes distal bowel toglucose and other stimulants of L-cell secretion of GLP-1.GLP-1 is the hormone required to decrease insulin resis-tance. Insulin resistance is normal. It is not the cause ofdiabetes. GLP-1 deficiency is the cause. Normal insulinresistance makes it possible for GLP-1 to regulate insulinaction. Both hormones are required. Hyperinsulinemia willbe avoided by providing the missing hormone. T2DM isGLP-1 dependent diabetes. T2DM is a disease of thedigestive tract. Bariatric and Metabolic Surgeons willunderstand normal dumping and how glucose mimetics orother poorly absorbed L-cell stimulants can reach the L-cells in distal bowel and prevent or resolve T2DM withoutsurgery. Dumping is required for an immediate effect of a

surgical procedure upon T2DM. You will understand thatwithout dumping, we would all have T2DM.Dorido’s sleeve gastrotomy (fundic invagination) should

be as successful as sleeve gastrectomy. My original goal ofdecreasing the need for stomach resection will again befulfilled. Complete stomachs will remain available by asimple reversal operation if needed later in life to providedigestion, dilution and perhaps normal dumping withgreater knowledge and the cohesion of paradigms. “Scien-tific Discipline Will Replace Empiric Craft.” My mentors,Owen and Sara Wangensteen, used this in a subtitle for theirhistory of surgery in 1978 [5].Thank you for the honor of speaking at this meeting and

thanks to all of those who made this possible. A specialthanks to Elias Darido and coworkers for their imaginationof invagination with internal anastomosis of the fundus tothe antrum. Save the stomach, using education, scientificstudy and clinical translation. Keep it simple, surgeon.

Edward E. Mason, M.D., F.A.C.S.Emeritus Professor of Surgery, University of Iowa School of

MedicineIowa City, Iowa

References

[1] W. Edwards Deming [page on the internet]. Wikipedia [updated 2014January 2015; cited 2014 December 15]. Available from: http://en.wikipedia.org/wiki/W._Edwards_Deming.

[2] Darido E, Overby DW, Brownley KA, Farrell TM. Evaluation ofgastric fundus invagination for weight loss in a porcine model. ObesSurg 2012;22(8):1293–7.

[3] Darido E, Moore JR. Comparison of gastric fundus invagination andgastric greater curvature plication for weight loss in a rat model of diet-induced obesity. Obes Surg 2014;24(6):897–902.

[4] Adelbaki TN, Huang CK, Ramos A, Neto MG, Talebpour M, SaberAA. Gastric plication for morbid obesity: a systematic review. ObesSurg 2012;22(10):1633–9.

[5] Wangensteen O, Wangensteen S. The rise of surgery. From empiriccraft to scientific discipline. London: Dawson Company, 1978.