Diabetes Care Volume 42, February 2019 331 Metabolic (Bariatric and Henry Buchwald1,2 and Jane N. Buchwald3 Nonbariatric) Surgery for Type 2 Diabetes: A Personal Perspective Review Diabetes Care 2019;42:331–340 | https://doi.org/10.2337/dc17-2654 Metabolic surgery can cause amelioration, resolution, and possible cure of type 2 diabetes. Bariatric surgery is metabolic surgery. In the future, there will be metabolic surgery operations to treat type 2 diabetes that are not focused on weight loss. These procedures will rely on neurohormonal modulation related to the gut as well as outside the peritoneal cavity. Metabolic procedures are and will always be in flux as surgeons seek the safest and most effective operative modality; there is no enduring gold standard operation. Metabolic bariatric surgery for type 2 diabetes is more than part of the clinical armamentarium, it is an invitation to perform basic research and to achieve fundamental scientific REVIEW knowledge. And the Lord God caused a deep sleep to fall upon Adam, and he slept; and he took one of his ribs, and closed up the flesh instead thereof, and the rib which the Lord had taken from man, made he a woman.... dGenesis 2:21-22 METABOLIC SURGERY In 1978, in the foreword to the book Metabolic Surgery (1), by author H.B. and Richard L. Varco, we defined the discipline of metabolic surgery “as the operative manipu- 1Department of Surgery, University of Minne- sota, Minneapolis, MN lation of a normal organ or organ system to achieve a biological result for a potential 2 ” “ ” Department of Biomedical Engineering, Univer- health gain. The procedure described in Genesis was an operative manipulation sity of Minnesota, Minneapolis, MN under general anesthesia on a “normal organ” to achieve a “biological result”;itwas 3Division of Scientific Research Writing, Med- metabolic surgery. write Medical Communications, Maiden Rock, As early as 1896, bilateral oophorectomy was used to cause temporary regression of WI breast cancer metastases (2). The 100-year heyday of peptic, primarily duodenal, ulcer Corresponding author: Henry Buchwald, buchw001@ surgery, from the late 19th century to the discovery of Helicobacter pylori, involved umn.edu operating on normal stomachs and vagus nerves to cure the pathologic lesion, a distal Received 19 December 2017 and accepted 17 July ulcer left untouched by the surgeon. This was metabolic surgery, as was the partial ileal 2018 bypass (Fig. 1) for the treatment of hypercholesterolemia, introduced in 1962 and © 2019 by the American Diabetes Association. Readers may use this article as long as the work 1963 (3,4). The partial ileal bypass was used as the intervention modality in the is properly cited, the use is educational and not Program on the Surgical Control of the Hyperlipidemias (POSCH) (5–8), the first for profit, and the work is not altered. More infor- randomized controlled trial to use metabolic surgery. POSCH was the first study mation is available at http://www.diabetesjournals definitively to demonstrate the benefits of marked cholesterol lowering in preventing .org/content/license. myocardial infarctions, peripheral vascular disease, and the need for coronary artery See accompanying article, p. 186. 332 Metabolic Surgery and Diabetes Diabetes Care Volume 42, February 2019 most of the small intestine in an obese malabsorptive, surgery. Thus, in 1973, patient, with bowel reconstruction by Printen and Mason (16) introduced an end-to-end jejunoileostomy and sep- gastroplasty. Their original procedure arate drainage of the bypassed bowel by consisted of a partial horizontal gastric an ileocecectomy (10). Varco never pub- transection, leaving a greater curvature lished this case. The first report of this conduit. In 1981, Laws and Piantadosi operation was published in 1954 by (17) made the restrictive pouch vertical Kremen et al. (11), also from the Uni- and narrowed the outlet with a Silastic versity of Minnesota. ring (Fig. 3). Mason (18) described his The JIB elicited excellent and lasting second-generation VBG in 1982, which Figure 1—Partial ileal bypass. A, division of weight loss but was associated with used a Marlex mesh band through a gas- ileum, 200 cm from the ileocecal valve; B, extensive early and late complications. tric window in a vertical pouch for out- ileocecostomy above appendiceal stump; C, tacking proximal end bypassed ileum, clo- These included electrolyte imbalances, let restriction. The VBG rapidly gained sure mesenteric defects. vitamin and mineral deficiencies, diar- in popularity and soon rivaled the RYGB rhea, gas bloat syndrome, oxalate kidney for dominance in the field. Over time, stones, steatohepatitis and progressive however, VBG patients began to regain liver degeneration, cutaneous pustular weight, and the operation fell into disuse. eruptions, and mentation difficulties. To avoid the complications of the surgery or dilation and stenting, concur- Various causative mechanisms for these JIB and yet maintain the weight loss rently with coronary arteriographic ar- problems were hypothesized, with the achieved by that procedure, Nicola rest of disease progression and induction greatest credence given to short bowel Scopinaro introduced the BPD operation. of actual plaque regression, as well as syndrome and bacterial overgrowth in His procedure consists of a horizontal prolonging life expectancy over 25 years the bypassed small intestine causing the hemigastrectomy with gastric pouch of follow-up. Today bariatric surgery is elaboration of toxins and alcohol. Over drainage by a Roux limb, at least 250 the most used of metabolic surgery pro- time, most of these problems were an- cm in length, anastomosed to a long cedures and is performed worldwide as ticipated and prevented or treated. How- biliopancreatic limb to form the com- part of the treatment armamentarium to ever, with the emergence of the RYGB, mon channel of ;50 cm (19) (Fig. 4). The combat the epidemic of morbid obesity. the JIB fell into disuse. Although there procedure avoids any stagnation of flow are JIB patients alive and doing well to- and, thereby, the potential for bacterial HISTORY OF BARIATRIC SURGERY day, 30–40 years after their operation, overgrowth, toxin formation, and alcohol To date, well over 50 operations have most of the JIB patients had their proce- production by fermentation. been suggested and tried for the man- dure reversed with the concurrent estab- The Scopinaro procedure was subse- agement of morbid obesity (9) (Table 1). lishment of another bariatric operation. quently transformed into the DS, first One might therefore conclude that the In 1966, Mason and Ito (12) introduced by Marceau et al. (20) of Canada, who most suitable or ideal operation has, as the gastric bypass. Their operation con- performed a vertical sleeve gastrectomy yet, not been conceived. This is true, as it sisted of a horizontal gastric division with cross-stapling of the duodenum is true in any area of surgery and certainly with a loop gastrojejunostomy. Alden and an ;100-cm common channel. Duo- in medicine in the prescription of drugs. (13) modified the Mason procedure by denal cross-staplingis, however,unstable, More importantly, it illustrates the vigor cross-stapling the upper stomach and causing negation of the operative effect. and imagination of the proponents of draining the upper pouch by a loop Hess and Hess (21), in the U.S., conceived bariatric surgery. In the chronology of op- gastrojejunostomy. Within 1 year, Griffen the modern BPD/DS or DS, by dividing erative procedures, there are six histori- et al. (14) reported the first bypass with the duodenum and constructing a prox- cally dominant operations that have been a Roux-en-Y gastrojejunostomy, which imal duodenoileostomy (Fig. 5). successful in causing marked weight became the standard RYGB (Fig. 2). As The BPD and the BPD/DS are difficult, loss and that have had a major ef- cited (15), Pories and coworkers at the time-consuming operations that can tax fect on the field. Listed in chronologi- University of East Carolina should also the skill of many surgeons. They are also cal order of their introduction they are be credited for independently introduc- associated with long-term protein and jejunoileal bypass (JIB), Roux-en-Y gastric ing the Roux-en-Y drainage for the RYGB. other nutritional deficiencies and possi- bypass (RYGB), vertical banded gastro- The RYGB became the most widely ble liver failure. The surgeon and patient plasty (VBG), biliopancreatic diversion performed bariatric procedure worldwide committed to these procedures must, (BPD) or duodenal switch (DS), adjust- and has retained a position of prominence therefore, also be committed to metic- able gastric banding (AGB), and sleeve for more than 50 years. The complica- ulous lifelong follow-up. The salient ad- gastrectomy (SG). In addition, three oper- tion rate with the RYGB is low, patient vantages of these procedures are the ative innovations warrant mention: gas- satisfaction is high, and the weight-loss most marked and lasting weight loss tric stimulation, vagal blockade, and, most failure rate, although progressive over and the highest percentage of resolu- importantly, banded RYGB. time, is minimal to moderate. tion of obesity comorbidities of any of The first bariatric nonresectional sur- Mason was always eager to simplify the bariatric operations (22,23). gery procedure was performed in 1953 bariatric procedures and minimize their The simplest weight-loss operation by Richard L. Varco at the University of side effects and complications. He has, that has been routinely performed is Minnesota. It consisted of bypass of therefore, favored restrictive, rather than AGB, introduced by Kuzmak (24). The care.diabetesjournals.org Buchwald and Buchwald 333 Table 1—Operations developed for the management of obesity JIB-related procedures RYGB-related procedures VBG-related procedures 1953: R.L. Varco (unpublished observations)d 1966: Mason and Ito (12)dhorizontal gastric 1973: Printen and Mason (16)dpartial end-to-end jejunoileostomy division with loop gastrojejunostomy horizontal gastric division with greater 1954: Kremen et al.