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Presidential

Address

Mainstreaming Henry Buchwald, President,

American

Bariatric MD, PhD

Society fey Bariatric

Surgery, 1998-1999

All whom earth-born laws divide; All mankind shall be as brothers. Friedrich Schiller “Ode to Joy” in Rheinische Thalia, 1786 text, fourth movement Ninth Symphony of Ludwig van Beethoven Disdain of the obese is one of the last permitted prejudices in this country. In the United States, we consider it, at the very least, inappropriate to exhibit or tolerate bias against an individual because of his or her gender, color, religion, or ethnic origin. Furthermore, such intolerance violates the laws of the land. Yet, there are no laws against the daily prejudice directed toward the obese. There are no regulations or social mores to prohibit ill treatment, derision, and ostracism of the obese and, in particular, the morbidly obese. To laugh at the obese is not considered to be in bad taste. In fact, the obese are easily made the objects of low comedy. The final episode of Seinfeld, seen by millions of people, started with a robbery-observed, commented upon, and laughed at by the Seinfeld bunch. The show played the scene for extra humor by making the victim of the robbery obese. In order to change such a negative public perception and alter the status imposed on society’s obese members, we need to mainstream bariatric surgery. We must gain for bariatric surgery the full recogni-

Presented at the 16th Annual Meeting of the American Society for Bariatric Surgery. Reprint requests to: Henry Buchwald, MD, PhD, Box 290, Department of Surgery, University of Minnesota Hospital, 420 Delaware St. S.E., Minneapolis, MN 55455, USA. Fax: (612) 625-3206; e-mail: buchw001 @maroon.tc.umn.edu

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tion and acceptance of the medical community. We need to educate our colleagues. Our work must produce solid data. We have to promote basic research and clinical trial methodology. Most importantly, we must reason together with our fellow surgeons and physicians. We need to go the extra distance to achieve a sharing of thoughts and a concordance of ideas. We need to be flexible but not weak. We cannot leave unopposed the hopelessly biased and terminally recalcitrant. We know that morbid obesity is a disease. Establishing that fact is cardinal to the acceptance of surgical treatment for morbid obesity by the medical community. Medical management is directed toward disease entities, not social prejudices. A multitude of evidence supports a genetic predisposition with respect to body weight.lm3 Even greater documentation indicates that morbid obesity is an inborn error of metabolism, manifested by an impaired satiety mechanism and an abnormal conversion of ingested calories to fat, rather than their dissipation by body heat.4-7 Serious disease causes deaths, and actuarial data demonstrate that about 300,000 deaths annually in the United States are related to obesity.8 Obesity is in the ascendancy, since the number of overweight Americans has increased steadily and will continue to increase, because approximately 25% of today’s children are overweight or obese.9 We currently measure disease impact in dollars; obesity costs the United States about $100 billion annually in direct health care expenses and in lost productivity.lO The rhetoric of multifactorial origins and the influence of societal behavior in addition to genetics has become standard practice in discussing the genesis of obesity. However, once a body mass index (BMI) of 40, or even 35, is reached, obesity becomes morbid obesity, and morbid obesity is a disease. o 1999 Lippincott

Williams

B Wilkins,

Inc.

Mainstreaming For the medical community, and subsequently for the greater societal community, acceptance of the comorbid diseases of morbid obesity may be easier than the immediate acceptance of morbid obesity as a disease per se. Coronary heart disease and peripheral arterial occlusive disease were recognized clinical disease entities for decades before their causative process-atherosclerosis-was regarded as a disease of multifactorial origins, that can, nevertheless, be identified and independently treated. The comorbid diseases of morbid obesity include diabetes, hypertension, myocardial infarction, stroke, dyslipidemia, sleep apnea, Pickwickian syndrome, asthma, low back and disk disease, weight-bearing osteoarthritis, thrombophlebitis and pulmonary emboli, intertriginous dermatitis, urinary stress incontinence, gastroesophageal reflux disease, gallstones, and cirrhosis and carcinoma of the liver.‘l In addition, in women, infertility, uterine cancer, and breast cancer are also associated with morbid obesity.” Taken together, the many diseases caused by morbid obesity markedly reduce an individual’s odds of attaining an average life-span and raise annual mortality to lo-fold or more.12 The very presence of the comorbid diseases of morbid obesity brings numerous colleagues and disciplines into a working relationship with bariatric surgeons. In the past, cardiologists treated myocardial infarctions and angina, and vascular surgeons treated peripheral arterial occlusive disease, as isolated entities. Today, they treat or refer their patients for atherosclerosis source control, e.g., lipid management. The same trend to source management is happening with respect to cardiologists, pulmonologists, diabetologists, orthopedic surgeons, and other physicians asked to treat the comorbid diseases of morbid obesity. They are referring these patients for primary disease control to bariatric surgeons. Our dialogue for recognition of bariatric surgery with the medical community and with the population at large influences the battle with managed care providers and third-party payers. The process of reasoning with and educating health care insurers is key to obtaining appropriate health care coverage for the morbidly obese, including the right to undergo bariatric surgery. Only when the morbidly obese patient arouses the understanding and sympathy of the medical community, the public, and the society’s decision-makers will health care payers acknowledge that bariatric surgery is not only good medicine and humane, but, in the long run, profitable. As pointed out by former American Society for Bariatric Surgery (ASBS) president Dr. George

Bariatric

Surgery

S. M. Cowan, the morbidly obese are victims.13 We must, therefore, also seek the aid of legislators and the law to right the great wrongs inflicted on these victims of morbid obesity.

Progress,

1998-I

999

0 Friends, not these sounds! Rather let us give voice to something more pleasant and joyfil! Ludwig

van Beethoven, 1824, recitative introduction fourth movement, Ninth Symphony

Beethoven refers to sounds of discord and lamentation, comparable to the themes I have alluded to. Indeed, these themes of lamentation have been the subjects of discussion in the ASBS since its founding and have been addressed by many of our past presidents. Are we making any progress away from lamentation and toward achieving our objectives? I believe we have this past year, in dialogue with our fellow surgeons and our medical colleagues, gained peer acceptance for bariatric surgeons, centralization within American surgery of our efforts, and respect for our patients. We have come closer to mainstreaming bariatric surgery. We have made significant and mostly affirmative strides toward our goal. There is occasion for more pleasant and joyful sounds.

ACS Board

of Governors

The Board of Governors of the American College of Surgeons (ACS) was inaugurated in 1913 for the specific purpose of serving as the connecting link between the fellows of the ACS and its Board of Regents. Governors are the direct representatives of the fellows, and governors from the specialty societies serve as the liaison representatives between their specialty organization and the College. In July 1998, the ASBS officially applied for a governor position in the ACS, having fulfilled the requirements of having 400 surgeon members, the greater majority of whom are fellows of the ACS, and offering documentation of strong scientific/educational activities and programs for at least 5 years. In November 1998, we were notified that our request for a seat on the ACS Board of Governors had been approved. In May 1999, we were requested by the ACS to nominate a governor and an alternate, to be Obesity

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Buchwald reviewed and acted on by the College in October 1999. A voice on the ACS Board of Governors will grant the ASBS recognition in the organizational structure and in the workings of the ACS. This entitlement will allow the ASBS to gain knowledge of ACS policy statements as they are proposed and crafted, and to have input into their formulation before they are proclaimed. When this recognition occurs, we as a society, and bariatric surgery as a discipline, will have been accepted by the central pillar of American surgery.

ACS Bulletin

Publication

of ASBS

Guidelines

Since the fall of 1998, the ASBS has been working with the ACS’s Committee on Emerging Surgical Technology and Education (CESTE) on publishing guidelines for standards in bariatric surgery in the Bulletin of the American College of Surgeons. A draft of the guidelines, approved by the Executive Council of the ASBS, was submitted to CESTE. This draft has since undergone several rounds of editing and revisions by both the ACS and the ASBS. It has now been submitted for approval for publication by the ACS Board of Regents. The Bulletin, published continuously since January 1916, has always served as the house organ of the College. Founded in 1913 by surgeons in the United States and Canada, the ACS has focused on improving the quality of care of the surgical patient by setting high standards for surgical education and practice. In 1918, the ACS established the nation’s first hospital standardization program, which was designed to improve the quality of patient care in hospitals. The first volumes of the Bulletin were devoted largely to the propagation and administration of these hospital standards. Publication of the guidelines for standards in bariatric surgery will follow in this time-honored tradition of the Bulletin. With a current circulation of more than 68,000, the Bulletin is distributed without charge to ACS fellows, associate fellows, and candidates, as well as to medical libraries, medical schools, and other health care organizations in the surgical community.

ACS Annual

Meeting

Many of our ASBS members have presented papers on bariatric surgery at the annual meeting of the ACS. There has been, however, no major plenary session on bariatric surgery scheduled by the ACS 464

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program committee. For the 1999 annual meeting in October, the ACS program committee has planned a 4-hour plenary session dedicated to bariatric and plastic surgery in the care of the morbidly obese. This session will be organized and chaired by Dr. Harvey J. Sugarman.

Obesity

Coalition

The ASBS has been instrumental in forming a loose coalition of academic and advocacy societies for cooperative initiatives in the obesity field. This coalition consists of the ASBS, the American Obesity Association (AOA), the American College of Nutrition, the American Dietetic Association, the American Society for Bariatric Physicians, the American Society for Clinical Nutrition, the North American Association for the Study of Obesity (NAASO), the Obesity Law and Advocacy Center, and Shape Up America. The inaugural meeting of this coalition, attended by the presidents and executive directors of these societies, took place in Washington, DC, on November 9, 1998. To date, the ASBS has worked with the AOA and Shape Up America in submitting recommendations for obesity awareness and therapy to the draft statement of the Department of Health and Human Services “Healthy People 2010,” and in submitting reimbursement recommendations to the U.S. government in association with the ACS. With ASBS input, the AOA has recently published an article on obesity surgery in its newsletter, the AOA Advisor.

Day on the Hill On April 27-28,1999, several ASBS representatives were led by Christopher Gallagher and Christian Shalgian of the ACS on visits to the offices of 18 U.S. senators and representatives. Our dialogue with the congressional staff, and at times the officeholders, served to express ASBS support of “patient’s bill of rights” legislation. We also discussed fair representation for bariatric surgery in matters of obesity management by the National Institutes of Health (NIH) in their sponsored expert panels, consensus conferences, and preparation of published guidelines. The legislative process does not yield instant results. We have, however, been heard.

Education This past year saw the fruition of the commitment and hard work of Dr. John D. Halverson and the

Mainstreaming Preceptorship Committee: the initiation of ASBS preceptorships in bariatric surgery. In July 1998, under the guidance of Dr. Alex M. C. Macgregor, the ASBS received provisional accreditation for 2 years from the Accreditation Council for Continuing Medical Education (ACCME). For the annual ASBS meeting, our course, workshops, and program have expanded and have demonstrated an increased dedication to new technologies (e.g., laparoscopic bariatric surgery) and mechanisms of causation. ASBS booths have been used for physician education at other specialty meetings, and the Day in Surgery program has been successful in educating the influential lay public. The endeavors of the Allied Health Science program, under Mary Lou Walen’s leadership, have been primary assets for educating society at large about morbid obesity, the morbidly obese patient, and the needs of this patient before and after bariatric surgery.

NIH and NAASO

Guidelines

The near future will see publication of the NIH/ NAASO-sponsored Practical Guide to the ldentification, Evaluation, and Treatment of Overweight and Obesity in Adults. This resource for the practicing physician will have a significant impact on medical practice throughout the United States. Dietary therapy, behavior modification, physical activity, drugs, and bariatric surgery are the five management modalities for obesity discussed in this guide, and bariatric surgery is acknowledged as the most effective intervention for morbid obesity. Despite this realistic message, our participation in NIH policies and programs remained distressingly limited. Only in the very final stages of this guide’s preparation, and only after the ASBS exerted considerable pressure, were three active bariatric surgeons placed on the writing committee.

New Millennium

Objectives

Haste ye brothers, on your way Joyous as a knight victorious Friedrich

Schiller,

“Ode to Joy,” 1786

There is considerable progress as yet to be made toward mainstreaming bariatric surgery in the new millennium. I encourage you all to participate in this quest. I will touch on several areas that require

Bariatric Surgery

our efforts. In doing so, I am reminded of another presidential address in which Dr. James C. Thompson said to the Southern Surgical Association, “whenever you have the opportunity to chose a topic on which to speak, you should select something about which you feel strongly, even passionately.“14

NIH Policy

Reforms

In September 1998, the Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults-The Evidence Report was published.15 This is the template for the previously discussed, about to be published Practical Guide to the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. A significant amount of the material in the voluminous Evidence Report was concerned with bariatric surgery. The Evidence Report reluctantly acknowledged that for patients with a BMI over 40, bariatric surgery is the only intervention modality with a documented and meaningful record of success. The report, however, contained certain errors in the vocabulary of bariatric surgery, inventing terms to replace the standard ICD-9-CM AMA code for morbid obesity; defined operative procedures incorrectly; presented an outdated discussion of bariatric surgery complications; and gave an overview of the field that lacked a knowledgeable perspective. The three ASBS surgeons who were placed on the Practical Guide writing committee at the eleventh hour after months of struggling with the NIH were constrained by the already published contents of the Evidence Report from correcting errors that could and should have been avoided. The Evidence Report, as a position paper from the primary federal body responsible for setting national health policies, was written by an NIH-appointed expert panel. This panel, chaired by Dr. F. Xavier Pi-Sunyer, consisted of 24 individuals appointed by Dr. Claude Lenfant, Director of the National Heart, Lung and Blood Institute (NHLBI). Not a single representative of American surgery, much less from the national organization of surgeons treating morbid obesity-the ASBS-was on this panel! Instead, this “expert panel” included eight internists or individuals with positions in a department of medicine, five in preventive medicine or epidemiology, five in nutrition, two exercise physiologists, one psychologist, one family practitioner, one statistician, and one FDA representative. And, again, not a single surgeon! This problem of being granted appropriate repreObesity

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465

Buchwald sentation on NIH panels is not unique to bariatric surgery; all of American surgery is poorly represented in certain NIH activities. The NIH today embodies a mindset that believes surgeons should be used but not heard. Only rarely is there a surgeon in the position of a decision-maker within the NIH. As a rule, when the NIH does consult surgeons, the ones picked do not represent national surgical bodies or the thinking of practitioners of the discipline. This state of affairs cannot be allowed to continue. NIH expert panels and committees to formulate, write, and disseminate documents and guides for the practicing physician, as well as NIH consensus conferences and other public policy-setting activities, must include active clinicians representing all of the major academic societies and disciplines in that particular field. As long as this basic tenet of fair play is violated, various segments of the patient population of the United States will continue without representation and may be harmed. As an analogy, I have never seen an NIH-appointed group of surgeons chosen to set guidelines for pharmaceutical modalities of treatment. The NIH needs to reform its policy of excluding surgeons from surgical concerns. Such a policy may also be discriminatory under applicable public laws enacted by Congress since 1964 and through executive orders pertaining to federal agencies. This fight is worth the effort. We must persevere in our efforts to include bariatric surgery in NIHsponsored policies and research affecting the up to 10 million morbidly obese Americans we treat. If we succeed in mainstreaming bariatric surgery at the NIH, American surgery at large also succeeds. We need to commit our resources, organize other surgical associations, and work publicly to expose and correct this untenable state of affairs. The NIH, in addition to sponsoring research, guides the thinking of American physicians and the practice of American medicine. The doctrines espoused by the NIH influence daily what we do, what we are allowed to do, and what we are expected to do. We must see to it that the NIH fulfills its mission appropriately.

and to judicial mandates to obtain parity for our patients. We have to become advocates. If we cannot educate certain of our colleagues, we need to educate the public’s elected representatives. To this end, the ASBS makes its annual pilgrimage to Capitol Hill. Members of our surgical society have given freely of their time to place before legislators facts that they may not have been aware of and to correct misconceptions that they may have formed. I believe we are making progress through this initiative to achieve our goal of mainstreaming bariatric surgery. During the current Congress, a real opportunity exists to pass a meaningful patient’s bill of rights. Such a bill may mandate external, as well as internal, physician review of prior authorization and reimbursement decisions by insurance carriers. These external reviewers would consist of practitioners in the treatment area under consideration-surgeons to adjudicate surgery, bariatric surgeons to adjudicate bariatric surgery. Such a bill may also include a provision to permit taking an insurance carrier to court for sustained damages and, possibly but unlikely, for punitive damages. Furthermore, the concept of federal government-designated “centers of excellence” for bariatric surgery may become a topic for discussion and possible legislation. National efforts for legislative reform need to be reinforced by efforts at the local government level. Local bodies can act sooner and can undertake issues of concern that will not surface at the national level. Our membership may have considerable influence in state houses. As a complement to seeking legislative redress, it is time for us to enter the courts in support of our patients. The morbidly obese must be championed as plaintiffs for justice. The agencies of society must be stopped from denying the morbidly obese insurance coverage, jobs, education, and advancement. Current national disability statutes may be a means to grant the morbidly obese the rights and advantages granted to other Americans. Let us encourage the law to be a friend to the morbidly obese. Let us see to it that right is done.

Insurance Legislative

and Legal

Reforms

If reason does not prevail, if justice cannot be obtained by dialogue, if data and science are not heeded, and if informed physicians are excluded from the setting of national medical guidelines and policies, we need to turn to the legislative process 466

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Reforms

Our patients have the right to effective treatment, and we have the right to adequate compensation for our services. For all my belief in the power of people reasoning together, I have the least confidence in our ability to reason with insurance companies. To them, the morbidly obese represent unwanted consumers and bariatric surgeons represent

Mainstreaming unwanted providers. Currently, insurance companies frequently deny treatment, prolong the time to treatment, reduce fees, procrastinate, and obfuscate by all the bureaucratic means at their disposal. They work within a narrow customer turnover timeline in which source-control care of the comorbid diseases of the morbidly obese is not profitable. Their concern is for the annual bottom line, not for service to the ill. In order to achieve insurance reforms in bariatric surgery, we must encourage appropriate legislation and uphold legal redress. We must also work to eliminate society’s bias against the morbidly obese and to foster empathy for this segment of our population. In one aspect or another, every individual on the planet belongs to a minority defined by a physical or a disease characteristic. If one disease group can be ostracized and discriminated against, then other groups can be as well. This realization may promote universal sentiments of fellowship. As I have stated, to convince society, we have to educate and enlist the help of our peers in medicine. If greater American medicine supports bariatric surgery, the public will support bariatric surgery, and the insurance carriers will come to the table.

Residency

Training

and Board

Certification

The future treatment of morbid obesity will consist of drugs to replace, augment, or suppress the abnormal biochemical body milieu responsible for this disease. I have no doubt that we will some day be able to modulate, by pharmaceutical agents, the body’s intrinsic satiety mechanism, its metabolic rate, and the destiny of ingested calories. Preferably, such agents will be the body’s own transmitters and mediators. And, above all, without diminishing efficacy, they will enhance the patient’s quality of life and life expectancy. These agents, however, are not yet on the horizon. Until such safe measures are available, the field of bariatric surgery not only will be necessary but will expand. The expansion of bariatric surgery will be driven by several factors. We know that the number of obese and morbidly obese individuals in this country is increasing. Moreover, the minimum weight limit for bariatric surgery will inevitably be lowered, given the evolving appreciation that the comorbid diseases of obesity can be cured, ameliorated, and prevented by bariatric surgery; that bariatric surgery is safe; and that its benefits are long-lasting. I see this happening, in the near future, in two areas in particular: control of type II

Bariatric Surgery

diabetes and treatment of gastroesophageal reflux disease (GERD). Diabetologists are keenly aware that the very best they can offer type II diabetic patients is weight control, and the data to support performing bariatric procedures for diabetic patients 50 to 75 pounds overweight are becoming increasingly available. The surgical management of GERD continues to evolve through a hodgepodge of procedures, several depending on achieving just the right degree of tension at the esophagogastric junction. Roux-en-Y gastric bypass, on the other hand, provides total acid and bile control and, thereby, reflux control in a predictable and uniform manner. Most important to the expansion of bariatric surgery will be the influence of laparoscopic procedures: operations similar to current open procedures, as well as banding operations introduced in the laparoscopic era. Laparoscopic bariatric surgery has arrived and will expand, possibly to dominate this field. We in the ASBS have always maintained that a bariatric surgeon must first be a general surgeon and then a dedicated specialist in bariatric surgery. In similar fashion, we must insist that a laparoscopic bariatric surgeon must first be a skilled laparoscopic surgeon and then a dedicated specialist in laparoscopic bariatric surgery. Neither open nor laparoscopic bariatric surgery can tolerate the unskilled surgeon or the occasional performer who has little interest in morbidly obese patients and their multifactorial care. The expected increase in the volume of bariatric surgery makes it inevitable that bariatric surgery will be mainstreamed into surgical residency training programs. To this end, the ASBS preceptorship program is a valuable bridge. Laparoscopic surgery is currently part of the residency training curriculum, and the introduction of laparoscopic bariatric surgery will increase resident’s exposure to bariatric surgery. Not only is the number of bariatric surgeons increasing, but so are the number of training programs with bariatric surgeons, the number of bariatric procedures performed in training programs, and academic awareness and research in the management of morbid obesity. Bariatric surgery provides residents an opportunity to learn how to do many basic surgical techniques and how to expose the upper abdomen. Above all, residents themselves are expressing an interest in bariatric surgery. They, possibly more so than certain of their mentors, see a bright future in bariatric surgery-a field that is expanding, interesting, and satisfying. As bariatric surgery becomes a greater part of Obesity Swgey, 9, 1999 467

Buchwald surgical residency training, it should also become a greater part of the knowledge base and experience required by the American Board of Surgery. Bariatric surgery is general surgery, and the American Board of Surgery represents the attainment of proficiency and expertise in general surgery. The ASBS will strive to integrate the didactic and practical aspects of bariatric surgery into the Board’s requirements. I call upon the Board to reciprocate by increasing its emphasis on bariatric surgery in the in-service examination and in the written and oral examinations for Board certification. The current Board requirements for endoscopic and laparoscopic procedures followed a phase-in period, as the Board gave notice to training programs that these aspects of general surgery would become Board requirements. The Board should follow a similar process of assimilation with respect to bariatric surgery.

Publications,

Presentations,

and Presence

The annual ASBS meeting has matured. We now teach, discuss, and present our best research and clinical achievements in an atmosphere comparable with that of the most elite of American specialty societies. Similarly, Obesity Surgery has matured into a highly respected journal, the primary source for the latest information and analyses in the field of bariatric surgery. We should present our best work at our annual ASBS meeting and in our journal. Yet, if we are to mainstream bariatric surgery, we must also broaden our affiliations. We must assimilate more closely with other groups and publish more widely in other journals. It is incumbent on us to attend regional and academic society meetings, as well as the annual ACS meeting. More of us need to submit abstracts for oral presentations, videos, and posters on bariatric surgery at such meetings. Our reaching out for inclusion and dialogue must extend to submitting papers to journals in basic science, obesity research and management, and general surgery. We need to continue to encourage reciprocal visits and guest lecturers between the ASBS and the medical groups in the obesity field. To this end, the formation of our new obesity coalition has already achieved tangible results in communication. Will this broadening of our presentations and publications diminish our own meeting and our own journal? On the contrary. I believe the universalization of bariatric surgery will only increase the 468

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prestige of the annual ASBS meeting, enhancing the science presented and the attendance achieved. Similarly, Obesity Surgery will increase its readership and thereby increase the number of articles submitted for publication. We must have the courage to follow these convictions. We must make our presence known.

A Personal

Note

He that‘s had that best good fortune, To his friend a Fiend to be, Friedrich

Schiller,

“Ode to Joy,”

1786

I have lived a good part of the history of bariatric surgery, as has my department of surgery at the University of Minnesota, especially under Dr. Owen H. Wangensteen. Dr. Richard L. Varco, my mentor, probably performed the first intestinal bypass specifically to induce weight reduction in 1953, although he never published this achievement. The first published report was that of Kremen, Linner, and Nelson in 1954, all of whom were Minnesota trained.16 Another early contributor to the development and subsequent critical assessment of jejunoileal bypass surgery was Dr. Peter A. Salmon, my chief resident when I was a junior E. Mason, resident at Minnesota. l7 Dr. Edward the father of gastric restrictive surgery, was a Minnesota product: he introduced gastric bypass (1966),18 gastroplasty (1971),19 and vertical banded gastroplasty (1982). 2o The report of Dr. John F. Alden, from Minnesota, of 100 successive gastric bypasses, without gastric transection and without a death, was a landmark.‘l So was the article by Dr. Ward 0. Griffen, stressing the advantages of Roux-en-Y gastrojejunostomy over loop gastrojejunostomy. ** Before Dr. Griffen went to Lexington, Kentucky, and subsequently headed the American Board of Surgery, he was another of my chief residents and attendings at Minnesota. An astute observer and contributor of knowledge on gastric restrictive procedures is former ACS president Dr. Lloyd D. MacLeanz3-yet another University of Minnesota residency trainee. I have now performed nearly 2,500 bariatric procedures, have made some minor technical innovations in this field, and have attempted to maintain the University of Minnesota tradition in bariatric surgery. How did I get started in this area? In 1965, after Dr. Varco injured the median nerve in his right arm, he asked me to do bariatric

Mainstreaming

surgery and enter this field of his interest. I refused, explaining my wish to have my name associated only with the partial ileal bypass operation and hyperlipidemia. One day he passed me in the hall, angrily shook his casted arm at me, and stated that he would do bariatric surgery if he could. I relented. I have never regretted this decision. Dr. Varco’s misfortune proved to be most fortuitous for me. I rapidly learned to empathize with my patients. I realized that the morbidly obese were severely handicapped, with a disease that is a harbinger of a multitude of fatal diseases. I also realized that because of their disease, they are singled out by society for ridicule, discrimination, and social and medical maltreatment. I know of no other cohort of patients that is blamed so vehemently and so robbed of their self-esteem, merely for having the misfortune of suffering from a congenital metabolic disease. I became not only a bariatric surgeon but an advocate for the morbidly obese. I have been the beneficiary of this dedication. When I see a patient who has sustained a significant weight loss; who has achieved or advanced in employment; and who is healthy, accepted, and happy, I am more than amply rewarded. The ASBS is a unique society in the annals of American medicine. Ours is the only group with so many facets to its mission: patient care, research, academic discourse, education, professional standards, surgical access, reimbursement, liability, communication, and patient advocacy. We successfully mix physicians and allied health science specialists in nutrition and lifestyle management. We consist of an extraordinary blend of university and community surgeons. The ASBS represents some of the finest surgeons in the world: bariatric surgery is not technically simple, and the care of the morbidly obese patient requires a detailed knowledge of complex cardiopulmonary conditions, diabetes, and other comorbid diseases. Bariatric surgeons probably offer the best long-term follow-up care of their patients of any group of surgical specialists. We consider this commitment part of our job. For all these reasons, the ASBS has the right to be proud. And I am proud to be part of the ASBS. I thank you for the honor you bestowed upon me by making me your 13th president. I have done my best this past year to mainstream bariatric surgery, and I hope to continue toiling in this vineyard for years to come. I thank my wife and children for their understanding and unwavering support of my aspirations to aid the morbidly obese. I again thank the ASBS

Bariatvic

Surgery

membership for the opportunity given to me to serve the morbidly obese. I have truly “had that best good fortune, to his friend [patients and colleagues alike] a friend to be.”

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