The American Journal of Surgery (2015) 209, 779-782
North Pacific Surgical Association: Historian’s Lecture
The evolution of bariatric surgery Preston L. Carter, M.D.* Department of the Army, Western Regional Medical Command, Madigan Army Medical Center, Tacoma, WA 98431, USA KEYWORDS: Surgical history; Bariatric surgery; Obesity
Bariatric surgery has been one of the great medical success stories of the late 20th century. From 1970, when fewer than 10 obesity-related articles were published in major North American surgical journals, weight control surgery is now a major component of the General Surgery specialty. Before 1970, only a few dozen bariatric cases were performed annually, in dramatic contrast to the hundreds of thousands now done each year worldwide. This remarkable transformation was in no small way aided by concurrent advances in surgical stapling technology and the laparoscopic revolution. Younger surgeons may not fully appreciate the challenges faced by the bariatric surgical pioneers operating in an era of far less sophisticated instrumentation and lighting in the operating room, and less refined knowledge of optimal postoperative care for a massively obese patient. In 1970, Dr H. William Scott, a pioneer bariatric surgeon, stated the case for bariatric intervention succinctly, if bluntly: When an obese individual attains the Gargantuan level of the fat man or fat woman in the circus, I believe the
Presented at the Annual North Pacific Surgical Association meeting, November 15, 2014, Seattle, Washington. * Corresponding author. Tel.: 11-253-968-2200; fax: 11-253-968-5337. E-mail address: [email protected] Manuscript received December 2, 2014; revised manuscript December 28, 2014
0002-9610/$ - see front matter Published by Elsevier Inc. http://dx.doi.org/10.1016/j.amjsurg.2014.12.026
term morbid should be added to emphasize the serious health implications and life-shortening hazards of such grotesque accumulations of fat. Individuals who fit into this unfortunate category suffer enormous psychologic, social, and economic consequences as well.1
As this quote makes clear, surgery for severe obesity is intended primarily ‘‘to attack the root cause of a myriad of secondary obesity-related health issues,’’ some of which are listed in Table 1. Although there is room for debate on whether bariatric interventions should be strictly limited to the most severely obese patients, already suffering from secondary health issues, or offered more liberally before secondary health damage is done, all would agree that bariatric surgery is absolutely ‘‘not’’ intended as a cosmetic intervention, or solely to get the patient to a lower number on the scales. In the early days, weight loss surgeons were often seen as mavericks. It is now abundantly clear that the surgical options, which have evolved over the last 40 years, offer the best presently available means of not only reversing the severe obesity itself, but also dramatically improving the weight-connected health and quality of life issues alluded to by Dr Scott. Much has been learned in nearly 2 generations of bariatric surgical experience. As in other areas of surgery, today’s better outcomes are a result of lessons learned from yesterday’s failures. This brief review of bariatric surgical development is mainly intended to give historical perspective, and is not an attempt to cover the subject in detail. Illustrations, more detailed descriptions of many of the procedures mentioned, and related scientific outcome analyses are readily available
780 Table 1
The American Journal of Surgery, Vol 209, No 5, May 2015 Major obesity-related conditions
Type 2 diabetes Hypertension Sleep apnea Steatohepatitis Esophageal reflux Metabolic syndrome Polycystic ovary syndrome Urinary incontinence Degenerative joint disease Venous stasis and lymphedema Medically significant pannus Pseudotumor cerebri Depression Limitation of employment opportunity
via internet query as well as in the referenced journal citations. Medically significant obesity was recognized by Hippocrates, but was rare before the 20th century in a time of less robust diets and more arduous physical demands in day to day living. If a person did become ‘‘morbidly’’ obese, thenprevailing medical wisdom was that the condition was self-inflicted, and until mid-century, these unfortunate individuals were sometimes exhibited as carnival ‘‘freaks.’’ The medical profession had little to offer a severely overweight patient beyond blandishments to exercise more, eat less, or to be admitted for hospital-based prolonged starvation. Failure to control one’s weight was seen almost exclusively as a defect of will, not a consequence of altered metabolism. In the 1960s, as the population increasingly shifted from rural to city life and pre-prepared convenience foods and beverages changed dietary habits, obesity rates soared. Throughout North America, morbid obesity becamedquite literallyda wide-spread problem. Although ‘‘diet and exercise’’ advice is philosophically sound, for the severely obese it is dismally ineffective, and evidence emerged that in part severe obesity results from causative factors separate from simple summations of calories in versus calories out. Stunkard et al1 showed that children born of obese biologic parents but raised by lean adoptive parents had strong likelihood of growing to adult weights which more closely mirrored their ‘‘biologic’’ rather than their adoptive parents, implying a genetic component to adult obesity. In a study at the Vermont State Prison (truly a ‘‘captive environment’’), the legendary obesity researcher, Sims, deliberately overfed volunteer inmates for several months, who were probably delighted to get a break from the usual jailhouse diet. Despite marked and prolonged overfeeding, some prisoners proved to be ‘‘natural ectomorphs,’’ who gained weight only with difficulty and quickly returned to their original weight at study’s end.2 These observations gave credence to the hypothesis that severe obesity is in
fact a complex, multifactorial disease, and not a condition to be exclusively blamed on the patient. Many surgical procedures have come and gone over the years, but all currently accepted bariatric options that derive from 2 fundamental insights by the bariatric pioneers: altering small bowel absorption or limiting gastric capacity. The earliest bariatric series came from a Los Angeles surgeon, Dr J. Howard Payne, whose results came from limiting small bowel absorption. Building on earlier experimental canine work in Minnesota by Kremen3 showing weight loss when there was major exclusion of the distal small bowel from the alimentary stream, he devised a ‘‘jejunocolic shunt,’’ wherein the uppermost 50 cm of jejunum anastomosed directly to the transverse colon. All remaining downstream small bowel was left in situ as a long blind end.4 Not surprisingly (in retrospect), this jejunocolic arrangement often caused significant metabolic derangements, and led Payne to a new arrangement, which connected the proximal 35 cm of jejunum end-to-side to the terminal 10 cm of ileum, thus preserving the ileocecal valve. This operation, the ‘‘jejunoileal bypass’’ (JIB), became, in various modifications, the first widely popular bariatric operation nationally, for which there was a bandwagon of enthusiasm in the 1970s. There were advocates for either Payne’s ‘‘end-to-side’’ construct or for Scott’s alternative ‘‘end-to-end’’ JIB, with end-to-end jejunoileostomy, with the defunctionalized small bowel vented by a separate anastomosis to the colon.5 With either of these strategies, weight loss was often impressive and better than all prior nonsurgical therapies. However, over time it became apparent that JIB could also cause major liver or kidney damage. The increasing prevalence of these complications led to abandonment of JIB as a surgical therapy in North America, but in Europe, the Italian surgeon Scopinaro devised an alternative small bowel bypass procedure, known as biliopancreatic diversion.6 This procedure, combined with subtotal gastrectomy, somewhat resembled JIB, limiting small bowel absorption, but with much more food contact length than in classic JIB. The Scopinaro procedure also critically differed from JIB by preserving biliary and pancreatic flow through the bypassed small bowel. Although not free of nutritional side effects, his outcomes were better overall than those of classic JIB. Scopinaro’s procedure was a forerunner to the modern duodenal switch (DS) operation. The strategy of limiting gastric capacity was pioneered by Dr Edward Mason, an Iowa surgeon. Having observed that substantial weight loss often followed subtotal gastrectomies for ulcer disease (then a relatively common operation), Mason partitioned off a 10% upper gastric ‘‘pouch’’ connected to a Billroth II loop gastrojejunostomy.7 To make the procedure potentially reversible, the 90% distal gastric remnant was left in situ as a blind end. Weight loss was good. Mason’s patients had few metabolic problems. However, the instrumentation and retractors of the era made the operation technically difficult. Acceptance was limited. As had been the case with JIB, variations on Mason’s original anatomic arrangement quickly emerged.
P.L. Carter
A brief history of weight loss surgery
To avoid bile reflux in the pouch, the original Mason loop ‘‘gastric bypass’’ was modified to Roux-en-Y anatomy. Seeking alternative ways to limit gastric capacity, Mason and others devised operations which left the small bowel undisturbed, but partitioned the stomach into a very small upper pouch connected by an internal channel to the distal stomach. Ever-better surgical staplers popularized this simpler approach. Many ‘‘gastroplasty’’ variations emerged in the 1980s, with Mason’s vertical banded gastroplasty (VBG) becoming the most dominant.8 Unfortunately, as with JIB, initial widespread enthusiasm for ‘‘stomach stapling’’ gave way to disenchantment. Staple partitions often failed over time, with consequent weight regain. Even when the pouch remained anatomically intact, obstructing food impactions in the outlet channel were not uncommon. Some VBG patients, finding themselves unable to tolerate most solid foods, learned to subsist on nutritionally poor, high-calorie liquid diets (a phenomenon known as maladaptive eating), often with consequent weight regain. Another interventional weight control approach from the early days of bariatrics which failed to achieve widespread popularity or reliable efficacy was endoscopic deployment of an intragastric balloon to fill gastric space and give an earlier sense of satiety. In an effort to learn from these early bariatric efforts, Mason and other bariatric pioneers formed a dedicated bariatric surgical society, now known as the American Society for Metabolic and Bariatric Surgery. The American Society for Metabolic and Bariatric Surgery has become a major international forum for obesity research. Among its many contributions is the recognition of the importance of foregut hormones related to hunger and satiety, and the landmark discovery that type 2 diabetes usually dramatically and rapidly improves when ingested food is diverted from the duodenum, as in gastric bypass and DS.9 Current mainstream bariatric procedures evolved from these early-generation procedures. All seek to limit gastric capacity, with some also reducing the length of small bowel exposed to food. There are 4 major surgical options. The first, gastric banding,10 purely restricts food intake to achieve its effect, by implanting an inflatable silastic ‘‘doughnut’’ around the uppermost stomach at or very near the gastroesophageal junction, connected to a subcutaneous fill port. Saline volume in the port controls the tightness of the band. The ‘‘lap-band’’ approach has been heavily promoted commercially, both by some surgical groups and by the device makers themselves, touting its ‘‘minimally invasive’’ nature and reversibility. However, long-range results have been mixed at best, with widely variable weight control and VBG-like issues with vomiting and solid food intolerance. Substantial numbers of patients ultimately become dissatisfied and seek other options. Worldwide, weight control by banding seems to be on the wane. The anatomically simple sleeve gastrectomy11 is the newest major contemporary bariatric procedure, and is rapidly increasing in worldwide popularity. The entire lateral gastric body and fundus are resected, leaving behind a
781 small-diameter cylindrical lesser curve and about half of the antrum. Gastric capacity reduction approaches 90%. As the small bowel is untouched, weight control is solely from reduced food intake, but with possible synergistic satiety effects from loss of ghrelin-producing tissues in the resected stomach. This operation has the great virtue of pyloric preservation, and creates minimal nutritional risk. Simple to perform laparoscopically, it totally eliminates the risk of internal hernia complications seen with gastric bypass or DS. Although the phrase gastric bypass is certainly well known by the lay public, most remain fuzzy on its anatomic details. Roux-en-Y gastric bypass is a still-popular bariatric alternative, now in use for more than 40 years. It’s popularity rose exponentially following the successes of Wittgrove and others to perform the procedure laparoscopically.12 Shortterm results are usually good, but although seen only in a small minority of overall patients, the late complications of marginal ulcer or internal hernias can on occasion be serious or even life-threatening. Also, as years pass from the time of gastric bypass, some patients regain substantial weight. The reasons are not always clear, but after gastric bypass, food empties directly into the upper small bowel without pyloric control. Impressive post-bypass hypertrophy can then ensue in the roux limb and upper jejunum. This may enhance small bowel absorption and contribute to weight regain. The DS operation, pioneered by Hess,13 combines sleeve gastrectomy with a Scopinaro-like small bowel bypass. A sleeve gastrectomy, identical to that of a stand-alone sleeve, is formed. Several centimeters distal to the pylorus, the duodenum is then transected. The small bowel is divided approximately 250 to 300 cm from the ileocecal valve. From this transection point, a 150-cm roux ‘‘alimentary limb’’ is then anastomosed to the gastric end of the divided duodenum. As with a Scopinaro procedure, the distal duodenum is isolated from food contact and drains to a long biliopancreatic limb, the end of which is anastomosed to the alimentary limb about 100 to 150 cm from the ileocecal valve, creating a ‘‘common channel’’ region for digestive enzymes and food to come together. In a DS, about 60% to 70% of the small bowel is isolated from the foodstream, compared with only about 5% to 10% in ‘‘standard’’ gastric bypass constructions. This difference results in much less fat absorption in DS, compared with standard gastric bypass. DS weight control outcomes are the most robust and durable of the modern weight loss procedures. Pyloric preservation in DS allows patients to eat a varied diet with low risk of dumping. Nutritional supplement requirements are similar to gastric bypass, with an additional supplement requirement for the fat-soluble vitamins A, D, E, and K. Despite its favorable outcomes, DS has not gained widespread popularity. In an era with strong medical economic pressures against traditional open bariatric surgery, DS is a difficult procedure for many surgeons to safely perform laparoscopically which likely limits its use. In addition to these 4 current surgical mainstays, other possibilities continue to be explored. Noteworthy is gastric plication,14 a procedure in which the gastric greater curvature and fundus is infolded and sutured to itself, but without
782
The American Journal of Surgery, Vol 209, No 5, May 2015
resection, thus reducing gastric volume as with the sleeve procedure Gastric plication preserves the possibility of reversal, but is both more technically difficult than a sleeve and more difficult to standardize its residual gastric volume. It remains investigational. Much progress has been made from the early days of longer operative and hospitalization times, much higher complication rates, frequent intensive care stays, and less reliable outcomes. However, we should not deny that while much improved, modern bariatric surgery still entails some degree of risk and uncertainty, and not all patients reach optimal weight control. A further sobering reality is that in a time of rampant obesity, there is insufficient surgical capacity to operate on all patients who could potentially be helped. Those of us with long experience in this challenging surgical arena know that bariatric patients are often profoundly grateful for our help as they regain better control of their lives and see improvement in their health. Virtually all the comorbid conditions listed in Table 1 resolve or improve following an effective bariatric surgical intervention.15 Until the day comes when more effective nonsurgical obesity-control treatments exist, bariatric surgery remains by far the best path to better health for the severely obese.
2. Sims EA, Danforth E. Expenditure and storage of energy in man. J Clin Invest 1987;79:1019–25. 3. Kremen AJ, Linner JH, Nelson CH. An experimental evaluation of the nutritional importance of proximal and distal small intestine. Ann Surg 1954;140:439–48. 4. Payne JH, DeWind LT, Commons RR. Metabolic observations in patients with jejunocolic shunts. Am J Surg 1963;106:273–89. 5. Scott HW, Sandstead HH, Brill AB, et al. Experience with a new technic of intestinal bypass in the treatment of morbid obesity. Ann Surg 1971;174:560–72. 6. Scopinaro N, Gianetta E, Adami GF, et al. Biliopancreatic diversion for obesity at 18 years. Surgery 1996;119:261–8. 7. Mason EE, Ito C. Gastric bypass. Ann Surg 1969;170:329–39. 8. Mason EE. Vertical banded gastroplasty for morbid obesity. Arch Surg 1982;117:701–6. 9. 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;222:339–52. 10. Belachew M, Legrand M, Vincent V, et al. Laparoscopic adjustable gastric banding. World J Surg 1998;22:955–63. 11. Karmali S, Schauer P, Birch D, et al. Laparoscopic sleeve gastrectomy: an innovative new tool in the battle against the obesity epidemic in Canada. Can J Surg 2010;53:126–32. 12. Wittgrove AC, Clark GW, Tremblay LJ. Laparoscopic gastric bypass, Roux-en-Y: preliminary report of 5 cases. Obes Surg 1994;4:353–7. 13. Hess DW, Hess DS. Biliopancreatic diversion with a duodenal switch. Obes Surg 1998;8:267–82. 14. Brethauer SA, Harris JL, Kroh M, et al. Laparoscopic gastric plication for the treatment of severe obesity. Surg Obes Relat Dis 2011; 7:15–22. 15. Sugerman HJ, Baron PL, Fairman RP, et al. Hemodynamic dysfunction in obesity-hypoventilation syndrome and the effects of treatment with surgically induced weight loss. Ann Surg 1988;207: 604–13.
References 1. Stunkard AJ, Sorenson TI, Harris AC, et al. An adoption study of human obesity. N Engl J Med 1986;314:193–8.
North Pacific Surgical Association: Historian’s Lecture
The evolution of bariatric surgery Preston L. Carter, M.D.* Department of the Army, Western Regional Medical Command, Madigan Army Medical Center, Tacoma, WA 98431, USA KEYWORDS: Surgical history; Bariatric surgery; Obesity
Bariatric surgery has been one of the great medical success stories of the late 20th century. From 1970, when fewer than 10 obesity-related articles were published in major North American surgical journals, weight control surgery is now a major component of the General Surgery specialty. Before 1970, only a few dozen bariatric cases were performed annually, in dramatic contrast to the hundreds of thousands now done each year worldwide. This remarkable transformation was in no small way aided by concurrent advances in surgical stapling technology and the laparoscopic revolution. Younger surgeons may not fully appreciate the challenges faced by the bariatric surgical pioneers operating in an era of far less sophisticated instrumentation and lighting in the operating room, and less refined knowledge of optimal postoperative care for a massively obese patient. In 1970, Dr H. William Scott, a pioneer bariatric surgeon, stated the case for bariatric intervention succinctly, if bluntly: When an obese individual attains the Gargantuan level of the fat man or fat woman in the circus, I believe the
Presented at the Annual North Pacific Surgical Association meeting, November 15, 2014, Seattle, Washington. * Corresponding author. Tel.: 11-253-968-2200; fax: 11-253-968-5337. E-mail address: [email protected] Manuscript received December 2, 2014; revised manuscript December 28, 2014
0002-9610/$ - see front matter Published by Elsevier Inc. http://dx.doi.org/10.1016/j.amjsurg.2014.12.026
term morbid should be added to emphasize the serious health implications and life-shortening hazards of such grotesque accumulations of fat. Individuals who fit into this unfortunate category suffer enormous psychologic, social, and economic consequences as well.1
As this quote makes clear, surgery for severe obesity is intended primarily ‘‘to attack the root cause of a myriad of secondary obesity-related health issues,’’ some of which are listed in Table 1. Although there is room for debate on whether bariatric interventions should be strictly limited to the most severely obese patients, already suffering from secondary health issues, or offered more liberally before secondary health damage is done, all would agree that bariatric surgery is absolutely ‘‘not’’ intended as a cosmetic intervention, or solely to get the patient to a lower number on the scales. In the early days, weight loss surgeons were often seen as mavericks. It is now abundantly clear that the surgical options, which have evolved over the last 40 years, offer the best presently available means of not only reversing the severe obesity itself, but also dramatically improving the weight-connected health and quality of life issues alluded to by Dr Scott. Much has been learned in nearly 2 generations of bariatric surgical experience. As in other areas of surgery, today’s better outcomes are a result of lessons learned from yesterday’s failures. This brief review of bariatric surgical development is mainly intended to give historical perspective, and is not an attempt to cover the subject in detail. Illustrations, more detailed descriptions of many of the procedures mentioned, and related scientific outcome analyses are readily available
780 Table 1
The American Journal of Surgery, Vol 209, No 5, May 2015 Major obesity-related conditions
Type 2 diabetes Hypertension Sleep apnea Steatohepatitis Esophageal reflux Metabolic syndrome Polycystic ovary syndrome Urinary incontinence Degenerative joint disease Venous stasis and lymphedema Medically significant pannus Pseudotumor cerebri Depression Limitation of employment opportunity
via internet query as well as in the referenced journal citations. Medically significant obesity was recognized by Hippocrates, but was rare before the 20th century in a time of less robust diets and more arduous physical demands in day to day living. If a person did become ‘‘morbidly’’ obese, thenprevailing medical wisdom was that the condition was self-inflicted, and until mid-century, these unfortunate individuals were sometimes exhibited as carnival ‘‘freaks.’’ The medical profession had little to offer a severely overweight patient beyond blandishments to exercise more, eat less, or to be admitted for hospital-based prolonged starvation. Failure to control one’s weight was seen almost exclusively as a defect of will, not a consequence of altered metabolism. In the 1960s, as the population increasingly shifted from rural to city life and pre-prepared convenience foods and beverages changed dietary habits, obesity rates soared. Throughout North America, morbid obesity becamedquite literallyda wide-spread problem. Although ‘‘diet and exercise’’ advice is philosophically sound, for the severely obese it is dismally ineffective, and evidence emerged that in part severe obesity results from causative factors separate from simple summations of calories in versus calories out. Stunkard et al1 showed that children born of obese biologic parents but raised by lean adoptive parents had strong likelihood of growing to adult weights which more closely mirrored their ‘‘biologic’’ rather than their adoptive parents, implying a genetic component to adult obesity. In a study at the Vermont State Prison (truly a ‘‘captive environment’’), the legendary obesity researcher, Sims, deliberately overfed volunteer inmates for several months, who were probably delighted to get a break from the usual jailhouse diet. Despite marked and prolonged overfeeding, some prisoners proved to be ‘‘natural ectomorphs,’’ who gained weight only with difficulty and quickly returned to their original weight at study’s end.2 These observations gave credence to the hypothesis that severe obesity is in
fact a complex, multifactorial disease, and not a condition to be exclusively blamed on the patient. Many surgical procedures have come and gone over the years, but all currently accepted bariatric options that derive from 2 fundamental insights by the bariatric pioneers: altering small bowel absorption or limiting gastric capacity. The earliest bariatric series came from a Los Angeles surgeon, Dr J. Howard Payne, whose results came from limiting small bowel absorption. Building on earlier experimental canine work in Minnesota by Kremen3 showing weight loss when there was major exclusion of the distal small bowel from the alimentary stream, he devised a ‘‘jejunocolic shunt,’’ wherein the uppermost 50 cm of jejunum anastomosed directly to the transverse colon. All remaining downstream small bowel was left in situ as a long blind end.4 Not surprisingly (in retrospect), this jejunocolic arrangement often caused significant metabolic derangements, and led Payne to a new arrangement, which connected the proximal 35 cm of jejunum end-to-side to the terminal 10 cm of ileum, thus preserving the ileocecal valve. This operation, the ‘‘jejunoileal bypass’’ (JIB), became, in various modifications, the first widely popular bariatric operation nationally, for which there was a bandwagon of enthusiasm in the 1970s. There were advocates for either Payne’s ‘‘end-to-side’’ construct or for Scott’s alternative ‘‘end-to-end’’ JIB, with end-to-end jejunoileostomy, with the defunctionalized small bowel vented by a separate anastomosis to the colon.5 With either of these strategies, weight loss was often impressive and better than all prior nonsurgical therapies. However, over time it became apparent that JIB could also cause major liver or kidney damage. The increasing prevalence of these complications led to abandonment of JIB as a surgical therapy in North America, but in Europe, the Italian surgeon Scopinaro devised an alternative small bowel bypass procedure, known as biliopancreatic diversion.6 This procedure, combined with subtotal gastrectomy, somewhat resembled JIB, limiting small bowel absorption, but with much more food contact length than in classic JIB. The Scopinaro procedure also critically differed from JIB by preserving biliary and pancreatic flow through the bypassed small bowel. Although not free of nutritional side effects, his outcomes were better overall than those of classic JIB. Scopinaro’s procedure was a forerunner to the modern duodenal switch (DS) operation. The strategy of limiting gastric capacity was pioneered by Dr Edward Mason, an Iowa surgeon. Having observed that substantial weight loss often followed subtotal gastrectomies for ulcer disease (then a relatively common operation), Mason partitioned off a 10% upper gastric ‘‘pouch’’ connected to a Billroth II loop gastrojejunostomy.7 To make the procedure potentially reversible, the 90% distal gastric remnant was left in situ as a blind end. Weight loss was good. Mason’s patients had few metabolic problems. However, the instrumentation and retractors of the era made the operation technically difficult. Acceptance was limited. As had been the case with JIB, variations on Mason’s original anatomic arrangement quickly emerged.
P.L. Carter
A brief history of weight loss surgery
To avoid bile reflux in the pouch, the original Mason loop ‘‘gastric bypass’’ was modified to Roux-en-Y anatomy. Seeking alternative ways to limit gastric capacity, Mason and others devised operations which left the small bowel undisturbed, but partitioned the stomach into a very small upper pouch connected by an internal channel to the distal stomach. Ever-better surgical staplers popularized this simpler approach. Many ‘‘gastroplasty’’ variations emerged in the 1980s, with Mason’s vertical banded gastroplasty (VBG) becoming the most dominant.8 Unfortunately, as with JIB, initial widespread enthusiasm for ‘‘stomach stapling’’ gave way to disenchantment. Staple partitions often failed over time, with consequent weight regain. Even when the pouch remained anatomically intact, obstructing food impactions in the outlet channel were not uncommon. Some VBG patients, finding themselves unable to tolerate most solid foods, learned to subsist on nutritionally poor, high-calorie liquid diets (a phenomenon known as maladaptive eating), often with consequent weight regain. Another interventional weight control approach from the early days of bariatrics which failed to achieve widespread popularity or reliable efficacy was endoscopic deployment of an intragastric balloon to fill gastric space and give an earlier sense of satiety. In an effort to learn from these early bariatric efforts, Mason and other bariatric pioneers formed a dedicated bariatric surgical society, now known as the American Society for Metabolic and Bariatric Surgery. The American Society for Metabolic and Bariatric Surgery has become a major international forum for obesity research. Among its many contributions is the recognition of the importance of foregut hormones related to hunger and satiety, and the landmark discovery that type 2 diabetes usually dramatically and rapidly improves when ingested food is diverted from the duodenum, as in gastric bypass and DS.9 Current mainstream bariatric procedures evolved from these early-generation procedures. All seek to limit gastric capacity, with some also reducing the length of small bowel exposed to food. There are 4 major surgical options. The first, gastric banding,10 purely restricts food intake to achieve its effect, by implanting an inflatable silastic ‘‘doughnut’’ around the uppermost stomach at or very near the gastroesophageal junction, connected to a subcutaneous fill port. Saline volume in the port controls the tightness of the band. The ‘‘lap-band’’ approach has been heavily promoted commercially, both by some surgical groups and by the device makers themselves, touting its ‘‘minimally invasive’’ nature and reversibility. However, long-range results have been mixed at best, with widely variable weight control and VBG-like issues with vomiting and solid food intolerance. Substantial numbers of patients ultimately become dissatisfied and seek other options. Worldwide, weight control by banding seems to be on the wane. The anatomically simple sleeve gastrectomy11 is the newest major contemporary bariatric procedure, and is rapidly increasing in worldwide popularity. The entire lateral gastric body and fundus are resected, leaving behind a
781 small-diameter cylindrical lesser curve and about half of the antrum. Gastric capacity reduction approaches 90%. As the small bowel is untouched, weight control is solely from reduced food intake, but with possible synergistic satiety effects from loss of ghrelin-producing tissues in the resected stomach. This operation has the great virtue of pyloric preservation, and creates minimal nutritional risk. Simple to perform laparoscopically, it totally eliminates the risk of internal hernia complications seen with gastric bypass or DS. Although the phrase gastric bypass is certainly well known by the lay public, most remain fuzzy on its anatomic details. Roux-en-Y gastric bypass is a still-popular bariatric alternative, now in use for more than 40 years. It’s popularity rose exponentially following the successes of Wittgrove and others to perform the procedure laparoscopically.12 Shortterm results are usually good, but although seen only in a small minority of overall patients, the late complications of marginal ulcer or internal hernias can on occasion be serious or even life-threatening. Also, as years pass from the time of gastric bypass, some patients regain substantial weight. The reasons are not always clear, but after gastric bypass, food empties directly into the upper small bowel without pyloric control. Impressive post-bypass hypertrophy can then ensue in the roux limb and upper jejunum. This may enhance small bowel absorption and contribute to weight regain. The DS operation, pioneered by Hess,13 combines sleeve gastrectomy with a Scopinaro-like small bowel bypass. A sleeve gastrectomy, identical to that of a stand-alone sleeve, is formed. Several centimeters distal to the pylorus, the duodenum is then transected. The small bowel is divided approximately 250 to 300 cm from the ileocecal valve. From this transection point, a 150-cm roux ‘‘alimentary limb’’ is then anastomosed to the gastric end of the divided duodenum. As with a Scopinaro procedure, the distal duodenum is isolated from food contact and drains to a long biliopancreatic limb, the end of which is anastomosed to the alimentary limb about 100 to 150 cm from the ileocecal valve, creating a ‘‘common channel’’ region for digestive enzymes and food to come together. In a DS, about 60% to 70% of the small bowel is isolated from the foodstream, compared with only about 5% to 10% in ‘‘standard’’ gastric bypass constructions. This difference results in much less fat absorption in DS, compared with standard gastric bypass. DS weight control outcomes are the most robust and durable of the modern weight loss procedures. Pyloric preservation in DS allows patients to eat a varied diet with low risk of dumping. Nutritional supplement requirements are similar to gastric bypass, with an additional supplement requirement for the fat-soluble vitamins A, D, E, and K. Despite its favorable outcomes, DS has not gained widespread popularity. In an era with strong medical economic pressures against traditional open bariatric surgery, DS is a difficult procedure for many surgeons to safely perform laparoscopically which likely limits its use. In addition to these 4 current surgical mainstays, other possibilities continue to be explored. Noteworthy is gastric plication,14 a procedure in which the gastric greater curvature and fundus is infolded and sutured to itself, but without
782
The American Journal of Surgery, Vol 209, No 5, May 2015
resection, thus reducing gastric volume as with the sleeve procedure Gastric plication preserves the possibility of reversal, but is both more technically difficult than a sleeve and more difficult to standardize its residual gastric volume. It remains investigational. Much progress has been made from the early days of longer operative and hospitalization times, much higher complication rates, frequent intensive care stays, and less reliable outcomes. However, we should not deny that while much improved, modern bariatric surgery still entails some degree of risk and uncertainty, and not all patients reach optimal weight control. A further sobering reality is that in a time of rampant obesity, there is insufficient surgical capacity to operate on all patients who could potentially be helped. Those of us with long experience in this challenging surgical arena know that bariatric patients are often profoundly grateful for our help as they regain better control of their lives and see improvement in their health. Virtually all the comorbid conditions listed in Table 1 resolve or improve following an effective bariatric surgical intervention.15 Until the day comes when more effective nonsurgical obesity-control treatments exist, bariatric surgery remains by far the best path to better health for the severely obese.
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