HISTORY
The first report of bariatric surgery was based on canine experiments done to understand the physiology of small intestines. This was later attempted on humans and was first published in the year 1954 by Arnold J Kremen. The procedure performed was the jejunoileal bypass (JIB) (Fig. 1.1). It was on a young obese patient with cardiac disease, who had significant weight loss and stabilization of cardiac disease. This patient continued to live until the age of 61.
Jejunoileal bypass procedures were popularized by Professor Richard Varco and Professor Henry Buchwald (Emeritus editor for the Obesity Surgery Journal and past President of IFSO), from the University of Minnesota.
The word “Morbid Obesity” was introduced by Payne (a surgeon), DeWind (a gastroenterologist), and Commons (a pathologist), to encourage insurance companies to cover bariatric surgical procedures. They performed an end-to-side jejunocolic shunt, which was performed in two stages.
4In the 1960s these were the two most common procedures being performed, making it an era of malabsorptive procedures. As the number of procedures increased the number of complications also increased, the most notable being liver failure in some patients. This liver failure mimicked alcohol-induced cirrhosis, which many surgeons blamed on the patients calling them “closet alcoholics.” Another interesting finding was that when surgeons excised the bypassed small bowel, this liver failure did not occur. Later investigators demonstrated that the bacterial overgrowth in the excluded segment of small bowel led to this complication and named it “enterohepatic syndrome.”
By the 1970s, there was enough data to show the high complication rates of these malabsorptive intestinal bypass procedures including malnutrition, vitamin deficiencies (especially of fat-soluble vitamins), electrolyte abnormalities, ketosis, iron malabsorption, hyperoxaluria, nephrolithiasis, migratory arthralgia and profound inflammation of synovial lined spaces. Based on these findings, the National Institute of Health (NIH) in 1978 proposed that “the risk–benefit ratio of intestinal shunting was too high to recommend routine use”. This led to the end of purely malabsorptive procedures like jejunoileal and jejunocolic bypass.
Mason and Ito reported the gastric bypass in 1967 wherein a divided upper third of the stomach was anastomosed side-to-side to a loop of jejunum (Fig. 1.2). This was based on the philosophy that “if allowing patients to eat large volumes of food and then interrupting absorption by short-circuiting the intestine did not work, perhaps limiting intake would”. This led to the birth of restrictive procedures. Gastric bypass was further modified making the gastrojejunostomy anastomosis smaller with subsequent reduction of the size of the gastric pouch.
5Alden/Griffith added the Roux-en-Y configuration to prevent the alkaline reflux associated with the procedure. Further research was focused on restrictive procedures.
Mason continued to develop newer procedures and in the mid-1970s, he along with Printen described the horizontal gastric partition with an opening along the greater curvature (Fig. 1.3). The procedure did not produce long-term weight loss and was abandoned. In the mid-1970s other surgeons namely Tretbar, Echout, Fabito, Laws, and O’Leary modified the vertical gastric partition and controlled the outlet using various devices ranging from chromic suture to a silicone ring. Mason modified this procedure to a vertical banded gastroplasty (VBG) which gained considerable popularity as a bariatric procedure (Fig. 1.4). The restrictive procedures had fewer complication rates as compared to the jejunoileal bypass and thus started gaining more acceptance. The development of staplers significantly contributed to the emergence of these restrictive procedures.
In the mid-1970s, Wilkinson and Peloso pioneered the gastric band (nonadjustable) placed around the upper part of the patient's stomach. In 1978, Hallberg, Forsell, and Kuzmak invented a silastic ring with a small balloon on its inner side which could be adjusted by a subcutaneously placed access port allowing the adjustment of the outflow of the pouch. This was the invention of the adjustable gastric band.
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As the restrictive procedures were emerging, surgeons were trying to understand the reasons of failure of malabsorptive procedures. In 1979, Nicola Scopinaro reported the biliopancreatic diversion (BPD) as a safer alternative to the JIB (Fig. 1.5). The BPD he described included a hemigastrectomy with a 200 cm alimentary limb and a 50 cm common channel. In BPD there were no reports of liver failure associated with JIB, and in fact, liver histology showed improvement 1 year after the surgery. This success of BPD over the JIB was due to avoidance of the blind loop by anastomosing to the gastric pouch. In 1986, Hess and Hess modified the original BPD by performing a sleeve gastrectomy instead of the hemigastrectomy (which was associated with postgastrectomy syndromes) with a duodenojejunal anastomosis (duodenal switch). By preserving the pylorus, this procedure had a lesser incidence of dumping and marginal ulcers as compared to Scopinaro's BPD. The common channel was also increased to 100 cm. Ren and Gagner performed the first laparoscopic DS in 1999.
The now, very popular, sleeve gastrectomy was actually performed as the first-stage procedure before BPD-DS in super-obese patients. It was based on the Magenstrasse & Mill operation reported by Johnston in 1987. It was developed as a safer and technically easier operation to the then common VBG and gastric bypass. In this operation a thin vertically-oriented tube of the stomach (Magenstrasse) along the lesser curvature is created (without excision) with the antrum preserved, referred to as the Mill, hence the name (Fig. 1.6). It is performed by creating a defect using a circular stapler in the antrum, and from there the stomach tube is created over a 30 Fr bougie. The outflow of the rest of the stomach is maintained through the antrum.7
The early 1990s saw a revolution with the introduction of laparoscopy. A technique which was earlier used, mainly by gynecologists for diagnosis, became therapeutic. Laparoscopic cholecystectomy opened the field for many other laparoscopic procedures. Wittgrove and Clark performed the first laparoscopic gastric bypass in 1993. With increasing experience of bariatric surgeons in laparoscopy along with benefits of laparoscopy, patient acceptance for this minimally invasive approach skyrocketed with increasing numbers of procedures performed worldwide.8
FURTHER READING
- Chousleb E, Rodriguez JA, O'Leary JP. History of the development of metabolic/bariatric surgery. In: The ASMBS Textbook of Bariatric Surgery. Springer, New York (NY). 2015. pp. 37–46.
- NIH Consensus Development Program (1991). Gastrointestinal Surgery for Severe Obesity. [online]. Available from https://consensus.nih.gov/1991/1991gisurgeryobesity084html.htm [Accessed January 2019].
- O'Brien PE, MacDonald L, Anderson M, et al. Long-term outcomes after bariatric surgery: fifteen-year follow-up of adjustable gastric banding and a systematic review of the bariatric surgical literature. Ann Surg. 2013;257(1):87–94.
- Scopinaro N, Adami GF, Marinari GM, et al. Biliopancreatic diversion. World J Surg. 1998;22(9):936–46.