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Professor Mervyn Deitel - a career in bariatric surgery

Bariatric News was delighted to speak with Professor Mervyn Deitel, one of the Founders of the American Society for Bariatric Surgery in 1983 in Iowa City and a President of the ASBS in 1995. He was one of the 13 Founders of the International Federation for the Surgery of Obesity (IFSO) in Stockholm in 1995, the first Executive Director of IFSO, and remains an Honorary Life Member. We spoke about his career in bariatric surgery…

Did you always want a career in medicine?

When I was really young I want to be an artist, then a scientist, and later specifically a doctor.  I had two older cousins who were doctors and I admired what they did and aspired to be like them.

Why did you decide to specialise in bariatric surgery, what attracted you to the specialty?

When I graduated from medical school, I wanted to become a surgeon. I trained in New York in GI and Head & Neck surgery, and in Buffalo in cancer surgery, and then Dallas where I performed trauma surgery. When I came back to Toronto, the Chief of Surgery wanted me to handle shock cases such as haemorrhagic and septic shock in the Trauma Unit. I soon realised that one of the major problems with patients was malnutrition, so in the 1960s for the first time in Canada, I started a treatment called intravenous hyperalimentation – which became known as total parenteral nutrition.

As nobody in Canada had done this before, the treatment was met with some scepticism. We were putting in central lines for long periods of time with very high concentrations of amino acids and sugar. Over time, I developed my own pump, and eventually we started infusing lipid emulsion, and later we wrote the original paper on liposyn concentrations (Wong KH, Deitel M. Studies with a safflower oil emulsion in total parenteral nutrition. Can Med Assoc J. 1981;125:1328-34).

GI fistulas were referred to me, and I found that by providing nutrition centrally, the leakage would immediately decrease, patients would gain weight, and survive.

"The sleeve may really be a VBG without the band, and we may be witness to a sleeve gastrectomy hoax"

I once treated a 500g premature newborn – the baby was so small that the nurse’s wedding ring would fit on the baby’s arm. I had to use the internal jugular vein which was the size of a hair, and thread down a catheter. Within a month, the baby could eat on his own, gained sufficient weight and is a healthy adult today.

Because I was treating starvation cases, in 1969 I started getting referrals of patients who were the opposite – massively obese with severe co-morbidities.

A urologist referred a female patient to me who had breakdowns of repairs for urinary incontinence. She weighed over 400lbs, and I performed a jejunoileal bypass and she subsequently lost a lot of weight. From then on, everyone started sending me their morbidly obese patients.

At first, the Chief of Staff at St Joseph’s Hospital wanted to stop me performing jejunoileal bypasses; however, he soon saw the benefits of the major weight loss and referred his godmother to me for obesity surgery.

The jejunoileal bypass got some bad press. I thought it was a good operation if the patient was followed closely, and its main failing was the development of renal stones years later in about 10% of patients.

Can you tell us how bariatric surgery has evolved during your career?

After the jejunoileal bypass, we started performing the loop horizontal gastric bypass, originated by Ed Mason. However, this operation often resulted in tremendous tension on the jejunal loop, and if the anastomosis ever leaked, the leak would probably prove fatal for the patient due to the egress of large quantities of bile, pancreatic and gastric juices. So the Roux-en Y gastric bypass was performed: a jejunal Roux-loop was brought up to the high gastric pouch so tension on the anastomosis was avoided. The RYGB provides a degree of restriction and malabsorption, and remains widely performed.   

Subsequently, various types of horizontal gastroplasties were tried: patients would lose weight for the first two years, but unfortunately the proximal gastric pouch and outlet would expand, leading to regain weight.

Then, in 1982, Mason reported his results from vertical banded gastroplasty (VBG), and this operation became widely adopted. The weight loss was terrific for three years, but patients then regained weight, usually because the pouch enlarged or the patients adapted their eating habits. The popularity of the VBG, which was a procedure of choice for 10-15 years, declined.

Interestingly, the published VBG results were excellent, but the devil was in the details as no-one could publish the results of patients lost to follow-up. Many patients were too embarrassed to return for follow-up because of weight regain.

Meanwhile, laparoscopic surgery took off and gastric banding entered the arena. There is plenty of talk about band failure, but if you watch the patient and achieve regular follow-up, the inflatable band has been effective. In fact, I know of many bariatric surgeons who themselves opted to have a band placed in them, and not one has had it removed.

The sleeve gastrectomy is on the rise, partly because it saves the US$3,000-$4,000 cost of the band. The sleeve costs the price of staples. We are also seeing the rise of gastric plication, which further saves cost, as sutures are used instead of staplers.

With regards to the sleeve, my prognostication is that many patients will slowly start to regain weight around years four and five, and will eventually require a further procedure.

The sleeve may really be a VBG without the band, and we may be witness to a sleeve gastrectomy hoax. I have reservations as to the accuracy of the data reported. If you look at the data closely, you will see that very many patients are lost to follow-up.

I hear sleeve surgeons discussing leaks (which are infrequent but serious) and talking about drainage, stents, TPN, jejunostomy tubes, etc. But they do not seem to mention that these patients may be going through “hell”: they have drains and tubes coming out of the abdomen and may experience pain for months, and are having multiple endoscopic procedures.

You founded the journal Obesity Surgery. What do you remember about its creation?

In 1990, a number of bariatric surgeons felt the need for a specialized journal on obesity surgery; many articles had been refused by the general surgical journals because of insufficient interest by their readers. But, there was also opposition from a number of members of the ASBS who felt that such a journal would be unscientific and non-academic. With difficulty, I found a start-up publisher in Oxford, England, who undertook Obesity Surgery, with me as Editor-in Chief in 1991. After some difficulties, I finally took over the publishing, including the editing, design, printing, subscriptions, mailing and advertising. The journal rose rapidly, as bariatric surgery became recognized as life-saving for individuals with refractory severe obesity. Obesity Surgery attained an Impact Ranking of 7th out of 149 surgical journals for 3 consecutive years, and in 2006 Springer Science took over as publisher.

Do you think the future for bariatric and metabolic surgery will be in refining current techniques or developing newer technologies?

There will likely be many adaptations on top of the gastric sleeve operation. I believe that there will be salvage of restriction in many cases by applying a silastic ring.  Furthermore, various malabsorptive techniques will likely be added to the gastric sleeve. The duodenal switch is a proven excellent operation. I also believe that the mini-gastric (one-anastomosis) bypass of Rutledge and its modifications will become mainstream, with an understanding of the malabsorption and its surveillance. Surgeons are now starting to realize that the MGB is a rather rapid, safe and effective operation, which can be modified with the patient’s BMI, and does not have an increased threat of cancer as some had postulated.

Endoscopic techniques will also become widely used for restriction as the technologies develop. They may be limited in what they can achieve long-term, as the stomach attempts to re-expand. Endoscopic techniques will be  especially used in revisional surgery.

Away from surgery, how do you relax?

The world continues to develop major problems. My wife and I avidly keep up-to-date with world events by watching RT America, Euro-News, Al Jazeera, BBC World, etc. (the mainstream media tends to have their own agenda).  I like to garden. We love to spend time with our five grandchildren, and our two sons, one a spinal surgeon and the other a radiologist.