552344
research-article2014
SJS0010.1177/1457496914552344Changing trends in bariatricsE. Lo Menzo, et al
Review
Scandinavian Journal of Surgery 0: 1–6, 2014
Changing Trends in Bariatric Surgery E. Lo Menzo, S. Szomstein, R. J. Rosenthal The Bariatric & Metabolic Institute, Section of Minimally Invasive Surgery, Department of General Surgery, Cleveland Clinic Florida, Weston, FL, USA
Abstract
Background and Aims: Bariatric surgery is considered the only long-lasting treatment for morbid obesity. Techniques and procedures have changed dramatically. We report on some of the major changes in the field. Materials and Methods: We reviewed some of the major changes in trends in bariatric surgery based on some landmark paper published in the literature. Results: We identified three major phases in the evolution of bariatric surgery. The pioneer phase was mostly characterized by discovery of weight loss procedures serendipitously from procedures done for other purposes. The second phase can be identified with the advent of laparoscopic techniques. This is considered the phase of greatest expansion of bariatric surgery. The metabolic phase derives from the improved understanding of the mechanisms of actions of the bariatric operations at the hormonal and molecular level. Conclusions: Bariatric surgery has changed significantly over the years. The safety of the laparoscopic approach, along with the better understanding of the metabolic changes obtained postoperatively, has led to a more individualized approach and also an attempt to expand the indications for these procedures. Key words: Bariatric surgery; trends; metabolic surgery; sleeve gastrectomy; gastric bypass; laparoscopy
Introduction It has been almost three decades since the National Institutes of Health (NIH) consensus conference has established that bariatric surgery is the only longlasting treatment for morbid obesity (1). Since then, bariatric surgery has undergone exponential growth,
Correspondence: Raul J Rosenthal, M.D., FACS, FASMBS The Bariatric and Metabolic Institute Section of Minimally Invasive Surgery Department of General Surgery Cleveland Clinic Florida 2950 Cleveland Clinic Boulevard Weston, FL 33331, USA Email: [email protected]
demonstrating superior long-lasting results when compared to other interventions, resulting in wide recognition and becoming a specialty of its own. Many factors contributed to this unique escalade or growth trajectory. Undoubtedly, the main cornerstone of the rise in popularity was the ability to perform such procedures with minimal morbidity and mortality due to the introduction of laparoscopic techniques in 1994 (2). Although initially lengthy and challenging, the laparoscopic operations were always characterized by decreased wound infections, bleeding, and ventral hernias, as well as shorter hospital stay while achieving comparable weight loss results. This is especially true in a group of patients in whom open operations had a high rate of short- and longterm complications. The confidence and popularity reached by the laparoscopic bariatric surgeons was such that even the nonbariatric and nonlaparoscopic procedures bene-
2
E. Lo Menzo, et al
fited from the change in management of the postoperative period (abolition of nasogastric tubes, early feeding after anastomosis, early ambulation and discharge). This steep evolution would have not been possible without the advancement in laparoscopic technologies, in particular the introduction of ultrasonic energy and sophisticated cutters and stapling devices. Material and Methods We reviewed some of the most important papers in bariatric surgery in order to identify the historical and current trends of bariatric surgery. We describe some of the most important changes in the concepts of techniques, mechanism of action, and popularity of the different bariatric operations over the years. The choice of the paper reviewed was based on the need to highlight some of the major changes occurred in the acceptance of the different procedures and beliefs during the history of bariatric surgery. This is not meant to be a comprehensive review of all the landmark scientific papers in the bariatric surgery literature. Results Based on the review of the literature during the evolution of the bariatric specialty, we can arbitrarily identify several phases: 1. The pioneer phase; 2. The laparoscopic phase; 3. The metabolic phase. The Pioneer Phase
Initially, the serendipitous evidence that either removing or bypassing the intestine would determine weight loss leads to the development of the first bariatric procedure, the jejunoileal bypass (JIB), by Kremen et al. (3, 4). Although very effective for weight loss, and in spite of variations such as the jejunocolic bypass (JCB), the significant postoperative morbidities related to diarrhea, electrolyte disturbances, vitamin deficiency, and liver failure lead to the abandonment of such procedures (5). While Mason continued to propose procedures that combined restriction and malabsorption, describing the modern Roux-en-Y gastric bypass (RYGB), the idea of simply restricting the gastric volume continued to flourish. Among the several gastroplasties described in an effort to reduce the gastric volume, the vertical banded gastroplasty (VBG) deserves special attention, as this was the procedure with the overall longest longevity and wider application. First described by Mason (6) in 1982, VBG consists of the creation of a long narrow gastric pouch based on the lesser curvature with a banded narrow outlet. In spite of the respectable weight loss results (excess weight loss (EWL) up to 68%), the long-term complications of band erosion and weight regain from a gastro-gastric fistula are such that this procedure is now considered virtually of historic interest (7).
The idea of reducing the gastric volume by simply placing an extrinsic nonadjustable band was developed by Wilkinson in 1978 and applied more extensively by Molina (8) in 1980. It was in 1985 in Sweden by Hallberg and Forsell, and in 1986 in the United States by Kuzmak, that the modern era of adjustable gastric band began, initially with open techniques and then laparoscopically (9, 10). The placement of an adjustable band below the esophagogastric junction allows for the creation of a small gastric pouch of approximately 15 cm3. Since then, laparoscopic adjustable gastric banding (LAGB) increased in popularity on a yearly basis, while the gastric bypass remained the gold standard of bariatric operations. During the gastric bypass, a small (15–30 cm3) gastric pouch is created by completely dividing the proximal portion of the stomach from the rest. It is fundamental to completely exclude the more stretchable fundus of the stomach and basing the gastric pouch on the stiffer lesser curvature. The jejunum is then divided at a variable distance of 40–60 cm from the ligament of Treiz. The reconstruction is performed in a typical Roux-en-Y configuration with the jejunojejunostomy done at a distance between 100 and 200 cm to determine malabsorption. Although originally the belief was that the mechanism of action of the RYGB was based on the restriction and malabsorption created, several other potential changes seem to contribute to the overall effect of the procedure. Some of these changes will be discussed later on in “the metabolic phase” section of this article. The Laparoscopic Phase
As previously mentioned, the description of the first laparoscopic RYGB by Wittgrove et al. (2) in 1994 was one of the most important contributing factors for the sudden increase in popularity of bariatric surgery as well as the advancement of laparoscopic gastrointestinal procedures. The increased demand for bariatric surgeons caused the sprouting of a myriad of training programs and teaching courses. With the inevitable spike in popularity soon followed worrisome increase in complications, mostly due to the increased number of patients/cases. The need for standardization and uniformity of techniques and protocols led to the rise of “Centers of Excellence” (COE) in the United States. This need for organization was not limited to the technical aspect of the surgeries, but also encompassed the multidisciplinary support system for patients in both the preoperative and postoperative periods. The combination of structured training programs, standardization of techniques, advances in technology, and the organizational and reporting requirements of COE designation leads to the achievement of excellent results. In fact, the complication rates from each procedure became almost negligible (leak rate from gastric bypass of 12,000 cases. Surg Obes Relat Dis 2012;8(1):8–19. 18. Diamantis T, Apostolou KG, Alexandrou A et al: Review of long-term weight loss results after laparoscopic sleeve gastrectomy. Surg Obes Relat Dis 2014;10(1):177–183. 19. Hutter MM, Schirmer BD, Jones DB et al: First report from the American College of Surgeons Bariatric Surgery Center Network: laparoscopic sleeve gastrectomy has morbidity and effectiveness positioned between the band and the bypass. Ann Surg 2011;254(3):410–420;discussion 420–422. 20. Fridman A, Moon R, Cozacov Y et al: Procedure-related morbidity in bariatric surgery: a retrospective short- and mid-term follow-up of a single institution of the American College of Surgeons Bariatric Surgery Centers of Excellence. J Am Coll Surg 2013;217(4):614–620.
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E. Lo Menzo, et al
21. Abu-Jaish W, Rosenthal RJ: Sleeve gastrectomy: a new surgical approach for morbid obesity. Expert Rev Gastroenterol Hepatol 2010;4(1):101–119. 22. Perez M, Brunaud L, Kedaifa S et al: Does anatomy explain the origin of a leak after sleeve gastrectomy? Obes Surg. Epub ahead of print 30 April 2014. 23. Dimick JB, Osborne NH, Nicholas L et al: Identifying high-quality bariatric surgery centers: hospital volume or risk-adjusted outcomes? J Am Coll Surg 2009;209(6):702–706. 24. Van de Vrande S, Himpens J, El Mourad H et al: Management of chronic proximal fistulas after sleeve gastrectomy by laparoscopic Roux-limb placement. Surg Obes Relat Dis 2013;9(6):856–861. 25. Thompson CE, Ahmad H, Lo Menzo E et al: Outcomes of laparoscopic proximal gastrectomy with esophagojejunal reconstruction for chronic staple line disruption after laparoscopic sleeve gastrectomy. Surg Obes Relat Dis 2014;10(3):455–459. 26. Del Genio G, Tolone S, Limongelli P et al: Sleeve gastrectomy and development of “de novo” gastroesophageal reflux. Obes Surg 2014;24(1):71–77.
27. Santonicola A, Angrisani L, Cutolo P et al: The effect of laparoscopic sleeve gastrectomy with or without hiatal hernia repair on gastroesophageal reflux disease in obese patients. Surg Obes Relat Dis 2014;10(2):250–255. 28. Kruger RS, Pricolo VE, Streeter TT: A bariatric surgery center of excellence: operative trends and long-term outcomes. J Am Coll Surg 2014;218(6):1163–1174. 29. Pories WJ, Swanson MS, MacDonald KG et al: Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus. Ann Surg 1995;222(3):339–350;discussion 350–352. 30. Rubino F, Gagner M: Potential of surgery for curing type 2 diabetes mellitus. Ann Surg 2002;236(5):554–559. 31. Ryan KK, Tremaroli V, Clemmensen C et al: FXR is a molecular target for the effects of vertical sleeve gastrectomy. Nature 2014;509(7499):183–188.
Received: July 15, 2014 Accepted: August 14, 2014
research-article2014
SJS0010.1177/1457496914552344Changing trends in bariatricsE. Lo Menzo, et al
Review
Scandinavian Journal of Surgery 0: 1–6, 2014
Changing Trends in Bariatric Surgery E. Lo Menzo, S. Szomstein, R. J. Rosenthal The Bariatric & Metabolic Institute, Section of Minimally Invasive Surgery, Department of General Surgery, Cleveland Clinic Florida, Weston, FL, USA
Abstract
Background and Aims: Bariatric surgery is considered the only long-lasting treatment for morbid obesity. Techniques and procedures have changed dramatically. We report on some of the major changes in the field. Materials and Methods: We reviewed some of the major changes in trends in bariatric surgery based on some landmark paper published in the literature. Results: We identified three major phases in the evolution of bariatric surgery. The pioneer phase was mostly characterized by discovery of weight loss procedures serendipitously from procedures done for other purposes. The second phase can be identified with the advent of laparoscopic techniques. This is considered the phase of greatest expansion of bariatric surgery. The metabolic phase derives from the improved understanding of the mechanisms of actions of the bariatric operations at the hormonal and molecular level. Conclusions: Bariatric surgery has changed significantly over the years. The safety of the laparoscopic approach, along with the better understanding of the metabolic changes obtained postoperatively, has led to a more individualized approach and also an attempt to expand the indications for these procedures. Key words: Bariatric surgery; trends; metabolic surgery; sleeve gastrectomy; gastric bypass; laparoscopy
Introduction It has been almost three decades since the National Institutes of Health (NIH) consensus conference has established that bariatric surgery is the only longlasting treatment for morbid obesity (1). Since then, bariatric surgery has undergone exponential growth,
Correspondence: Raul J Rosenthal, M.D., FACS, FASMBS The Bariatric and Metabolic Institute Section of Minimally Invasive Surgery Department of General Surgery Cleveland Clinic Florida 2950 Cleveland Clinic Boulevard Weston, FL 33331, USA Email: [email protected]
demonstrating superior long-lasting results when compared to other interventions, resulting in wide recognition and becoming a specialty of its own. Many factors contributed to this unique escalade or growth trajectory. Undoubtedly, the main cornerstone of the rise in popularity was the ability to perform such procedures with minimal morbidity and mortality due to the introduction of laparoscopic techniques in 1994 (2). Although initially lengthy and challenging, the laparoscopic operations were always characterized by decreased wound infections, bleeding, and ventral hernias, as well as shorter hospital stay while achieving comparable weight loss results. This is especially true in a group of patients in whom open operations had a high rate of short- and longterm complications. The confidence and popularity reached by the laparoscopic bariatric surgeons was such that even the nonbariatric and nonlaparoscopic procedures bene-
2
E. Lo Menzo, et al
fited from the change in management of the postoperative period (abolition of nasogastric tubes, early feeding after anastomosis, early ambulation and discharge). This steep evolution would have not been possible without the advancement in laparoscopic technologies, in particular the introduction of ultrasonic energy and sophisticated cutters and stapling devices. Material and Methods We reviewed some of the most important papers in bariatric surgery in order to identify the historical and current trends of bariatric surgery. We describe some of the most important changes in the concepts of techniques, mechanism of action, and popularity of the different bariatric operations over the years. The choice of the paper reviewed was based on the need to highlight some of the major changes occurred in the acceptance of the different procedures and beliefs during the history of bariatric surgery. This is not meant to be a comprehensive review of all the landmark scientific papers in the bariatric surgery literature. Results Based on the review of the literature during the evolution of the bariatric specialty, we can arbitrarily identify several phases: 1. The pioneer phase; 2. The laparoscopic phase; 3. The metabolic phase. The Pioneer Phase
Initially, the serendipitous evidence that either removing or bypassing the intestine would determine weight loss leads to the development of the first bariatric procedure, the jejunoileal bypass (JIB), by Kremen et al. (3, 4). Although very effective for weight loss, and in spite of variations such as the jejunocolic bypass (JCB), the significant postoperative morbidities related to diarrhea, electrolyte disturbances, vitamin deficiency, and liver failure lead to the abandonment of such procedures (5). While Mason continued to propose procedures that combined restriction and malabsorption, describing the modern Roux-en-Y gastric bypass (RYGB), the idea of simply restricting the gastric volume continued to flourish. Among the several gastroplasties described in an effort to reduce the gastric volume, the vertical banded gastroplasty (VBG) deserves special attention, as this was the procedure with the overall longest longevity and wider application. First described by Mason (6) in 1982, VBG consists of the creation of a long narrow gastric pouch based on the lesser curvature with a banded narrow outlet. In spite of the respectable weight loss results (excess weight loss (EWL) up to 68%), the long-term complications of band erosion and weight regain from a gastro-gastric fistula are such that this procedure is now considered virtually of historic interest (7).
The idea of reducing the gastric volume by simply placing an extrinsic nonadjustable band was developed by Wilkinson in 1978 and applied more extensively by Molina (8) in 1980. It was in 1985 in Sweden by Hallberg and Forsell, and in 1986 in the United States by Kuzmak, that the modern era of adjustable gastric band began, initially with open techniques and then laparoscopically (9, 10). The placement of an adjustable band below the esophagogastric junction allows for the creation of a small gastric pouch of approximately 15 cm3. Since then, laparoscopic adjustable gastric banding (LAGB) increased in popularity on a yearly basis, while the gastric bypass remained the gold standard of bariatric operations. During the gastric bypass, a small (15–30 cm3) gastric pouch is created by completely dividing the proximal portion of the stomach from the rest. It is fundamental to completely exclude the more stretchable fundus of the stomach and basing the gastric pouch on the stiffer lesser curvature. The jejunum is then divided at a variable distance of 40–60 cm from the ligament of Treiz. The reconstruction is performed in a typical Roux-en-Y configuration with the jejunojejunostomy done at a distance between 100 and 200 cm to determine malabsorption. Although originally the belief was that the mechanism of action of the RYGB was based on the restriction and malabsorption created, several other potential changes seem to contribute to the overall effect of the procedure. Some of these changes will be discussed later on in “the metabolic phase” section of this article. The Laparoscopic Phase
As previously mentioned, the description of the first laparoscopic RYGB by Wittgrove et al. (2) in 1994 was one of the most important contributing factors for the sudden increase in popularity of bariatric surgery as well as the advancement of laparoscopic gastrointestinal procedures. The increased demand for bariatric surgeons caused the sprouting of a myriad of training programs and teaching courses. With the inevitable spike in popularity soon followed worrisome increase in complications, mostly due to the increased number of patients/cases. The need for standardization and uniformity of techniques and protocols led to the rise of “Centers of Excellence” (COE) in the United States. This need for organization was not limited to the technical aspect of the surgeries, but also encompassed the multidisciplinary support system for patients in both the preoperative and postoperative periods. The combination of structured training programs, standardization of techniques, advances in technology, and the organizational and reporting requirements of COE designation leads to the achievement of excellent results. In fact, the complication rates from each procedure became almost negligible (leak rate from gastric bypass of 12,000 cases. Surg Obes Relat Dis 2012;8(1):8–19. 18. Diamantis T, Apostolou KG, Alexandrou A et al: Review of long-term weight loss results after laparoscopic sleeve gastrectomy. Surg Obes Relat Dis 2014;10(1):177–183. 19. Hutter MM, Schirmer BD, Jones DB et al: First report from the American College of Surgeons Bariatric Surgery Center Network: laparoscopic sleeve gastrectomy has morbidity and effectiveness positioned between the band and the bypass. Ann Surg 2011;254(3):410–420;discussion 420–422. 20. Fridman A, Moon R, Cozacov Y et al: Procedure-related morbidity in bariatric surgery: a retrospective short- and mid-term follow-up of a single institution of the American College of Surgeons Bariatric Surgery Centers of Excellence. J Am Coll Surg 2013;217(4):614–620.
6
E. Lo Menzo, et al
21. Abu-Jaish W, Rosenthal RJ: Sleeve gastrectomy: a new surgical approach for morbid obesity. Expert Rev Gastroenterol Hepatol 2010;4(1):101–119. 22. Perez M, Brunaud L, Kedaifa S et al: Does anatomy explain the origin of a leak after sleeve gastrectomy? Obes Surg. Epub ahead of print 30 April 2014. 23. Dimick JB, Osborne NH, Nicholas L et al: Identifying high-quality bariatric surgery centers: hospital volume or risk-adjusted outcomes? J Am Coll Surg 2009;209(6):702–706. 24. Van de Vrande S, Himpens J, El Mourad H et al: Management of chronic proximal fistulas after sleeve gastrectomy by laparoscopic Roux-limb placement. Surg Obes Relat Dis 2013;9(6):856–861. 25. Thompson CE, Ahmad H, Lo Menzo E et al: Outcomes of laparoscopic proximal gastrectomy with esophagojejunal reconstruction for chronic staple line disruption after laparoscopic sleeve gastrectomy. Surg Obes Relat Dis 2014;10(3):455–459. 26. Del Genio G, Tolone S, Limongelli P et al: Sleeve gastrectomy and development of “de novo” gastroesophageal reflux. Obes Surg 2014;24(1):71–77.
27. Santonicola A, Angrisani L, Cutolo P et al: The effect of laparoscopic sleeve gastrectomy with or without hiatal hernia repair on gastroesophageal reflux disease in obese patients. Surg Obes Relat Dis 2014;10(2):250–255. 28. Kruger RS, Pricolo VE, Streeter TT: A bariatric surgery center of excellence: operative trends and long-term outcomes. J Am Coll Surg 2014;218(6):1163–1174. 29. Pories WJ, Swanson MS, MacDonald KG et al: Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus. Ann Surg 1995;222(3):339–350;discussion 350–352. 30. Rubino F, Gagner M: Potential of surgery for curing type 2 diabetes mellitus. Ann Surg 2002;236(5):554–559. 31. Ryan KK, Tremaroli V, Clemmensen C et al: FXR is a molecular target for the effects of vertical sleeve gastrectomy. Nature 2014;509(7499):183–188.
Received: July 15, 2014 Accepted: August 14, 2014
