History

Weight loss in relation to intestinal resection was observed in the late 19th century. Trzebicky16 first noted nutritional imbalances in canines following proximal and distal small-bowel resection. Weight loss in humans after gastric or small-intestinal resection was reported by Von Eiselsberg in 1895.2 Jensenius demonstrated that after distal small-bowel resection in a canine model, there was an increased loss of fat in the stool. Kremen later demonstrated that resection of greater than 50 percent of the distal small-intestine reduced fat absorption and resulted in weight loss, whereas lesser resections of proximal small intestine resulted in normal nutritional balance. Based on this work, Kremen performed the first therapeutic bariatric procedure, an end-to-end jejunoileostomy, in 1954. In 1955, Payne and Dewind performed the first clinical trial of obesity surgery. This trial of an intestinal bypass procedure was abandoned due to severe metabolic disturbances, liver failure, and protein-calorie malnutrition.17,18 The procedure was subsequently modified by anastomosing the proximal jejunum to the distal ileum, with the bypassed segment of small bowel anastomosed end-to-side to the colon, known as the jejunoileal bypass. This procedure was popular in the 1960 to 1970 era, and was very effective for weight loss. However, weight loss was complicated by significant electrolyte imbalances, vitamin deficiencies, intractable diarrhea, cholelithiasis, urolithiasis, neuromyopathies, and liver failure. As many as 25 percent of these patients required reversal of the jejunoileal bypass because of these complications, and the procedure was eventually abandoned.19

Mason and Ito developed the gastric bypass procedure for weight loss in the 1960s. Their work was based on the observation by Von Eiselsberg that weight loss often followed hemigastrectomy. In their report, 24 patients who had undergone Billroth II retrocolic gastrojejunostomy to a 100 ml gastric pouch with a 2 cm gastric outlet lost an average weight of 60 pounds at 18 months' follow-up.20 Electrolyte and vitamin deficiencies were manageable with supplementation, and liver dysfunction was unusual. In order to prevent bile reflux gastritis, Griff en modified the procedure by constructing a Roux-en-Y gastrojejunostomy instead of a Billroth II anastomosis.21 Even though many variations of the original procedure have been described, gastric bypass with a Roux-en-Y gastrojejunostomy remains an effective weight-loss operation with an acceptable complication rate.22

The era of purely restrictive procedures for the treatment of obesity came in 1971, when Printen and Mason introduced restrictive gastroplasty procedures.23,24 Gastroplasties were initially performed by partitioning the proximal stomach with a stapler, leaving a small (1 cm) gastric outlet along the greater curve. The staples were expected to hold the partition and opening in place for the lifetime of the patient. This would prove to be overly optimistic. The staple line frequently disrupted over 2 to 5 years with either the small gastric outlet dilating or the partition entirely failing. The end result was the same: Many patients lost significant amounts of weight only to regain it. Stapling and other surgical technologies continued to evolve over this time period. In 1982, Mason created a 2.5 cm circular defect with an end-to-end anastomosis (EEA) stapler approximately 8 to 9 cm below the angle of His and 3 cm from the lesser curve, and a polypropylene mesh collar was placed around the gastric outlet.25

The era of malabsorption returned in 1981, when Scopinaro and coworkers26 in Italy reported their initial results with biliopancreatic bypass (BPD). The BPD combines a subtotal gastrectomy with a Roux-en-Y gastroileal anastomosis and a jejunoileal anastomosis 50 cm proximal to the ileocecal valve to allow absorption of nutrients in the distal 50 cm common channel. Results reported by Scopinaro and coworkers have been excellent, with reduction in excess weight of nearly 75 percent. Complications associated with the procedure are protein malnutrition and malabsorption of vitamins; severe complications, such as liver failure, are rare, but they do occur. To reduce these complications, Marceau and associates27 in Canada modified the technique of Scopinaro and developed the biliopancreatic diversion with a duodenal switch (BPD-DS). It is constructed by performing a sleeve gastrectomy instead of subtotal gastrectomy, a Roux-en-Y duodenoileal anastomosis, and an ileoileal anastomosis 100 cm proximal to the ileocecal valve. Excellent results have been reported, and malabsorption complications have been less significant.

Another commonly performed restrictive procedure is adjustable gastric banding (AGB). The banding devices, usually made of silicone, compartmentalize the proximal stomach into a small pouch.28 There is currently one FDA-approved device for sale in the USA, Inamed's Lap-Band. AGB was first introduced in the 1990s.29 The adjustable band has a saline-injectable, subcutaneous reservoir that is tunneled in the subcutaneous tissue of the abdominal wall and connected to an inflatable silicone band that is wrapped around the proximal stomach. If weight loss is inadequate or symptoms of outlet obstruction arise, the silicone band can be inflated or deflated with saline, thereby changing the size of the gastric restriction.

Not long after the introduction and rapid acceptance of laparoscopic cholecystectomy, surgeons began performing laparoscopic bariatric procedures. Chelala30 and Belachew31 and their colleagues reported performing laparoscopic adjustable gastric banding in 1992. Laparoscopic Roux-en-Y gastric bypass and laparoscopic vertical-banded gastroplasty were reported in 1993 by Wittgrove32 and Lonroth33 at different institutions. Initial results of laparoscopic bariatric surgery have validated its safety and feasibility.33 34

In summary, bariatric surgery evolved over the second half of the 20th century. Even though the ideal procedure has yet to be devised, surgery has emerged as the most effective treatment for sustained, significant weight loss in the morbidly obese.

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