History of Bariatric Surgery
The field of weight loss surgery has remained dynamic over the last 5-6 decades. For many centuries obesity was seen as a sign of affluence due to food scarcity, but due to technological and healthcare advancement, it is now recognized as a health problem.
The first procedure that was done to achieve weight loss was jaw wiring. This was based on the belief that forcefully preventing an obese individual from excessive eating will result in weight loss. It was however discontinued as such patients were still able to drink liquids with high-calorie content leading to weight gain. They also suffer from dental infections and vomiting due to poor oral hygiene.
The current weight loss surgeries began from the observation by Kremen et al. in 1954. Part of the small intestine of a dog was resected, and a significant weight loss following this. This finding was supported by weight loss in people who lost part of their small intestine even with consumption of more calories.
With the knowledge that most nutrients are absorbed in the small intestine, most of the early bariatric surgeries were focused on small intestinal resection or refashion. Removal of a significant length of the small intestine often results in decreased nutrient absorption. Intake of food with high sugar content also leads to dumping syndrome characterized by nausea, bloating, diarrhea, excessive sweating, headache, etc. All these symptoms discourage the individual from consuming high-calorie foods.
Many old surgeries such as jejunocolic and jejunoileal bypass and vertical banded gastroplasty are no longer performed due to their high complication rates.
The jejunocolic bypass was a weight loss surgery performed by Payne et al. in 1963. It is a malabsorptive surgery. The small intestine is divided at 50cm below the junction of the duodenum and the jejunum (i.e., 50com below the ligament of Treitz). The upper end is then anastomosed (joined) to the right end of the transverse colon while the lower end of the divide is closed to become a blind end. The procedure was complicated by diarrhea and was later modified. The modification involves the anastomosis of the upper end of the divide to the beginning of the ascending colon. This type of surgery was discontinued due to severe malnutrition and its attendant complications, diarrhea, and electrolyte imbalance.
Jejunoileal bypass involves the division of the small intestine at 35-50 cm and anastomosis of the upper end of the divide to the side of the distal part of the small intestine at about 10cm from where it joined the large intestine (i.e., end-to-side anastomosis at 10cm before the ileocecal valve). Payne and DeWind promoted this procedure in 1969.
The jejunoileal bypass was modified by Scott Jr. et al. in 1976. Instead of an end-to-side anastomosis, they made another division on the small intestine at 10cm from the ileocecal valve and did an end-to-end anastomosis while the upper end of this new division was joined to the sigmoid colon. This modification was claimed to have caused more weight loss because it abolished reflux into, and absorption of nutrients in, the bypassed segment.
Due to excessive overgrowth of bacteria in the bypassed segment and its attendant effects on the other body organs such the liver and joints, the unbearable effects of nutritional imbalance and the high mortality rate of up to 4%, the jejunoileal bypass is no longer done.
The biliopancreatic diversion was the first bariatric surgery that combined restrictive and malabsorptive procedures. The procedure was first reported by Scopinaro et al. in 1979. The surgery involves a modification of the jejunoileal bypass and a restrictive procedure; resection of the distal part of the stomach leaving the proximal part to form a horizontal pouch. Biliopancreatic diversion significantly reduced the complications associated with jejunoileal bypass and also achieved a higher weight loss.
Biliopancreatic diversion with duodenal switch
In a biliopancreatic diversion, the pylorus of the stomach is resected, and this led to dumping syndrome and marginal ulcers. Marceau in 1993, therefore, modifies this procedure by conserving the pylorus of the stomach. He achieved this by resecting the stomach along the greater curvature. This resulted in a sleeve-like stomach. The small intestine is then divided at about 250cm from the ileocecal valve, with the upper end of the divide anastomosed with the terminal ileum at 50cm from the ileocecal valve and the lower end of the divide anastomosed with the upper end of the division at the duodenum while the distal end of the duodenal division is closed to become a blind end.
Other procedures that have been done in the past and now abandoned include gastric bypass plus loop gastrojejunostomy in the 1960s by Manson, horizontal gastroplasty by Manson et al. in 1970s and Vertical banded gastroplasty developed in 1980 by Mason and Laws.
Bariatric Surgeries Today
Today, the field of bariatric surgery is dominated by three major surgeries namely: laparoscopic gastric sleeve surgery, laparoscopic Roux-en-Y gastric bypass surgery, and laparoscopic adjustable gastric banding. Although biliopancreatic diversion with duodenal switch is still made as a primary bariatric procedure in some centers, it is often reserved for super obese individuals and as a revision surgery following the failure of other methods.
The latest bariatric procedures today are: