Page 10 - IFSO-History-Book-Digital-File

CHAPTER ONE

History of Metabolic Bariatric Surgery

Henry Buchwald

Metabolic Surgery

This story does not start in the beginning. It starts somewhere in the middle. Metabolic surgery
existed for over fifty years before it was appreciated as a unique surgical discipline. The definition of
metabolic surgery offered in 1978 defined metabolic surgery as, “the operative manipulation of a
normal organ system to achieve a biological result for a potential health gain” [1]. Perhaps, the term
putatively should be added to precede normal.

Over sixty years before the introduction of bariatric surgery, Albert Schinzinger, at the Congress of
the German Society for Surgery, in 1889, submitted an abstract that suggested that bilateral
oophorectomy would palliate metastatic breast cancer [2]. He never performed the procedure. Six
years later, George T. Beatson, in England, did the first bilateral oophorectomy for metastatic breast
cancer with excellent palliative outcomes. He subsequently became known as the Father of
Endocrine Replacement in Cancer Management [3].
Over the next fifty years, approximately twenty metabolic surgery procedures were introduced,
including splenectomy for idiopathic thrombocytopenia purpura and adrenalectomy for Cushing’s
hypertension. The most prolific metabolic surgery worldwide of the time was surgery for peptic ulcer
disease, particularly that of the duodenum. Without knowledge of H. pylori in peptic ulcer
neogenesis, surgeons resected various parts of the stomach, divided whole or selectively the
perigastric vagus nerves, and lysed the pyloric sphincter, all to induce healing of the untouched
pathologic lesion - the duodenal ulcer.

In 1953, bariatric surgery was originated for the treatment of severe obesity. Richard L. Varco, at the
University of Minnesota, in the United States (US), performed a bypass of most of the small intestine
in a patient with obesity with bowel reconstruction by an end-to-end jejunoileostomy and separate
drainage of the bypassed bowel by an ileocecostomy. Varco never published his case, but it was
documented in the patient’s hospital file [4]. Concurrently, in Sweden, Victor Henrikson, performed
a 105-cm bowel resection for the specific purpose of initiating weight loss [4]. In 1954, Kremen,
Linner, and Nelson, also from the University of Minnesota, published the first definitive report of the
Varco procedure [5]. Bariatric surgery, the concept of performing a surgical operation for severe
obesity, was vehemently opposed by many at first; nevertheless, it started to proliferate and
diversify.

Thus, one of the most prevalent surgeries of the 20th century, peptic ulcer surgery, and one of the
most prevalent surgeries of the 21st century, bariatric surgery, are examples of a new surgical
discipline, undefined for nearly one hundred years. The three basic past surgical principles of
incisional surgery (e.g., draining fluid collections), extirpative (e.g., resecting tumors), and

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