Father of bariatric surgery reflects on its past, present

This year, doctors are expected to perform 140,000 bariatric surgeries. That's a number researchers never dreamed of when they developed the procedure 50 years ago as a byproduct of experiments studying nutrition absorption in dogs, says surgeon John H. Linner, MD.

As a resident at the University of Minnesota in Minneapolis, Dr. Linner, along with his mentor Arnold Kremen, MD, and fellow researcher Charles Nelson, MD, discovered that the dogs lost weight after they underwent operations bypassing much of their intestines.

After Dr. Linner went into private surgical practice, one of his patients asked him to use the technique on her in the hopes that she, too, would shed some pounds.

The Annals of Surgery published the results of that procedure in September 1954, and bariatric surgery was born.

AMNews recently interviewed Dr. Linner, who retired from practice in 1996 and is now a Food and Drug Administration consultant on new methods to treat obesity.

Question: Who was your first case?

Answer: It was done for a woman who was very unhappy with her overweight. Her height was 5 feet 4 inches, and her maximum weight had been 375 pounds. When we operated on her in March 1954, she weighed 285 pounds.

I had talked to her about what we had encountered in our experiments in dogs. We had learned that, with a very short intestine, a lot of fat was lost in the stool and the dogs lost weight. She said, well, I wish you could do the same thing for me. So we did, and bypassed two-thirds of the small bowel.

Q: What happened to her?

A: She only lost 70 pounds. Two years later, I did it again. This time, it was much shorter lengths [of intestine]. Her weight got down to 170 pounds, and she was extremely happy about it. She was still overweight, but so much less so than before. She could bowl again and do other things. She lived another 22 years and did very well.

Q: How did you choose the earliest patients?

A: We were very strict in our indications, demanding that patients be at least 100 pounds overweight and that they had really tried everything to lose weight unsuccessfully.

If they had comorbidities, as so many of them did have, that was a further indication. That standard still applies.

Q: What was the reaction to the paper?

A: This developed so much interest. Within a year, surgeons around the country started doing intestinal bypasses.

But the interest was not all positive. There were many doctors who felt that being that obese and not getting on a diet or whatever it takes to lose weight conservatively was almost a character defect and if they couldn't do it, too bad.

Q: How many surgeries did you do over your career?

A: About 2,000. I left the field temporarily after the initial surgery because I was watching what was developing. I knew that other people were going to start doing this operation, and thought I would wait and see what their results were before I'd get back into it.

By 1967, there were some very good results around the country, so I thought I'd start again.

Q: The procedure has changed a lot since the first one. What do you think are the most significant advances?

A: One of the big recent changes, of course, is the application of the laparoscopic method during these operations. There is somewhat more rapid recovery and return home, when it's done right. Patient selection has also become more careful, and the preoperative workups and the post-op is better than it used to be.

Q: What are your thoughts on the fact that the surgery is being carried out on much younger people, such as children as young as 12?

A: If it's done by doctors, surgeons and clinics that have a lot of experience with this and are prepared to follow up closely, then it can be justified. But it has to be watched carefully. It is a greater risk.

Q: Do you think insurance should pay for it?

A: In the bona fide cases, insurance should pay for it.

Q: There have been reports of people gaining weight in order to qualify for the surgery. What do you think of that?

A: That's dishonest and not acceptable, but it does point out how desperate some of these people are. Depending on all associated circumstances, some of these patients should be denied surgery.

Q: Did you ever think bariatric surgery would become so popular?

A: Never.