Surgery for Obesity and Related Diseases 11 (2015) 286287

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 to
design a simple and reversible operation to replace gastric
resection. My sudden interest in obesity in 1966 was for a
disease to treat with gastric bypass. In 1966, after showing
in the laboratory that gastric bypass would decrease the
secretion of hydrochloric acid and not cause ulcers, I began
2 studies in patients. In 1 study of 8 patients with duodenal
ulcer, only 1 was cured. He was also morbidly obese and
lost a signicant amount of excess weight. A simultaneous
second study of using a loop gastric bypass to treat morbid
obesity was more successful, as you know.
How did you know that a loop bypass would lead to a
desirable weight loss procedure?
Many patients with peptic ulcer, treated with subtotal
gastrectomy and a loop gastroenterostomy lost weight, even
when they had a normal weight. They learned to eat smaller
meals more frequently and to avoid fattening foods that
caused dumping symptoms. Gastric bypass made a virtue
out of milder dumping, which for lean patients with ulcer
had been an undesirable, weight-losing side effect. My
mentor, Owen H. Wangensteen, told patients they would
live longer at a lower weight.
What drove you to organize the ASBS and ASBSR?
I had been considering establishing an American Society
for Bariatric Surgery, because I had hosted an obesity
surgery postgraduate course, the University of Iowa Obesity
Surgery Colloquium, for 7 years beginning in 1977. We
were obesity surgeons and physicians teaching each other.
We knew gastric bypass was curing diabetes in 1977, just as
had been observed following the introduction of intestinal
bypass in 1953. No obesity surgeon could fail to think
about such a benet. The mechanism nally became
evident. The common denominator between intestinal and
gastric bypass in resolving type 2 diabetes mellitus (T2DM)
was endogenous GLP-1 secretion by L-cells as a result of
short-circuiting the intestine and with dumping symptoms.

Glucose and other stimulants reached the L-cells before

they could be absorbed.
The American Society for Bariatric Surgery Registry
(ASBSR) was begun in 1985. It was voluntary and provided
for surgeons who wished to achieve continuous improvement in patient care. William Edwards Demings early
failure in the United States and success in Japan with the
Statistical Product Quality Administration, which is
thought to have been the system that was responsible for
the postwar Japanese miracle [1], was a stimulus to create
the ASBSR.
What do you envision the future of bariatric surgery
will be?
Sleeve gastrectomy is becoming the current operation of
choice. Unfortunately, sleeve gastrectomy is more complex
and irreversible. Epidemics of obesity and type 2 diabetes
have spread to adolescents and children. Fortunately, Elias
[3], and co-workers [2,3] have shown in rodent and growing
porcine models that the ballooning portion of the stomach
can be invaginated rather than resected [2,3].
The invaginated fundus is anastomosed internally to the
antrum, Fundic invagination could be called a sleeve
gastrotomy, since it is to sleeve gastrectomy as gastric
bypass is to gastric resection. My goal for gastric bypass
was to Keep it simple, surgeon and be reversible. I
envision sleeve gastrotomy as the operation of choice for all
ages and times. However, this procedure has not yet been
evaluated in humans. There have been a number of studies,
mostly from Iran, evaluating a gastric plication that may
also be a reversible weight loss procedure; however, longterm 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 as
physicians, patients, and the curious learn about dumping
for T2DM and stimulation of GLP-1 secretion. Record
keeping is no longer optional. You will learn how to make
scientic use of these data while preserving patient privacy.
This will require permission of the patient and participation
with special protection, perhaps for lifelong prospective
research. As always, prospective studies based upon

http://dx.doi.org/10.1016/j.soard.2015.01.008
1550-7289/r 2015 American Society for Metabolic and Bariatric Surgery. All rights reserved.

Editorial / Surgery for Obesity and Related Diseases 11 (2015) 286287

hypotheses will require collection of pertinent data. These

data may change with increasing knowledge of mechanisms
and consequences. You will explain to patients the normal
and therapeutic importance of dumping for stimulation of
GLP-1 secretion. You will explore and explain resolution of
T2DM with glucose mimetics that are poorly absorbed and
resolve T2DM when obesity is not a concern. The surgical
viewpoint will help resolve the obesity and T2DM epidemics in adults, adolescents, and children. You will
understand why only type 1 diabetes is insulin dependent.
T2DM is GLP-1 and dumping dependent. Some patients
with T2DM develop type 1 diabetes, and will then need
treatment for both types 1 and 2. This meeting is an
important step toward agreeable, science- supported viewpoints and optimal patient care. Severe obesity and T2DM
will, perhaps, be treated with surgery without stomach
resection if fundic invagination (sleeve gastrotomy)
becomes the standard of care. Further scientic laboratory
and translational clinical study is urgent and will be
ongoing 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 was
reported at the rst University of Iowa Obesity Surgery
Colloquium in 1977. You will know how hyperosmotic
ushing (also known as dumping) exposes distal bowel to
glucose and other stimulants of L-cell secretion of GLP-1.
GLP-1 is the hormone required to decrease insulin resistance. Insulin resistance is normal. It is not the cause of
diabetes. GLP-1 deciency is the cause. Normal insulin
resistance makes it possible for GLP-1 to regulate insulin
action. Both hormones are required. Hyperinsulinemia will
be avoided by providing the missing hormone. T2DM is
GLP-1 dependent diabetes. T2DM is a disease of the
digestive tract. Bariatric and Metabolic Surgeons will
understand normal dumping and how glucose mimetics or
other poorly absorbed L-cell stimulants can reach the Lcells in distal bowel and prevent or resolve T2DM without
surgery. Dumping is required for an immediate effect of a

287

surgical procedure upon T2DM. You will understand that

without dumping, we would all have T2DM.
Doridos sleeve gastrotomy (fundic invagination) should
be as successful as sleeve gastrectomy. My original goal of
decreasing the need for stomach resection will again be
fullled. Complete stomachs will remain available by a
simple reversal operation if needed later in life to provide
digestion, dilution and perhaps normal dumping with
greater knowledge and the cohesion of paradigms. Scientic Discipline Will Replace Empiric Craft. My mentors,
Owen and Sara Wangensteen, used this in a subtitle for their
history 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 special
thanks to Elias Darido and coworkers for their imagination
of invagination with internal anastomosis of the fundus to
the antrum. Save the stomach, using education, scientic
study 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 2014
January 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 of
gastric fundus invagination for weight loss in a porcine model. Obes
Surg 2012;22(8):12937.
[3] Darido E, Moore JR. Comparison of gastric fundus invagination and
gastric greater curvature plication for weight loss in a rat model of dietinduced obesity. Obes Surg 2014;24(6):897902.
[4] Adelbaki TN, Huang CK, Ramos A, Neto MG, Talebpour M, Saber
AA. Gastric plication for morbid obesity: a systematic review. Obes
Surg 2012;22(10):16339.
[5] Wangensteen O, Wangensteen S. The rise of surgery. From empiric
craft to scientic discipline. London: Dawson Company, 1978.