Surgery for obesity (Bariatric surgery) is not a new field but has been around for over 50 years. The first significant gastrointestinal operative procedures for weight loss were the intestinal bypasses. These procedures, first described in the 1950’s, involved the connecting (anastomosing) of the very proximal piece of the small intestine called the jejunum to the very distal part of the small intestine called the ileum, or even the colon. In doing so, approximately 90% of the small intestine’s absorptive surface area was no longer exposed to nutrients taken in. Although intestinal bypasses were successful for achieving significant weight loss, it came at the high price of significant complications. Patients universally suffered from chronic diarrhea and foul smelling flatus. Additionally many suffered from protein malnutrition, vitamin and macronutrient deficiencies, joint and muscle aches, and renal stones. Most troublesome, some patients developed cirrhosis and even liver failure. After decades of use, these procedures were no longer performed. In 1979, Dr. Nicola Scopinaro introduced a redesigned intestinal bypass called the “biliopancreatic diversion.” This procedure delivers significant weight loss results and does not have many of the severe long term consequences of the intestinal bypasses. A more recent variant is the biliopancreatic diversion with duodenal switch, or just “duodenal switch” for short (Figure 4). However, the complexity of these procedures and the risk of protein, vitamin, and mineral deficiencies have limited them to less than 5% of all bariatric procedures performed.
In the mid 1960’s, Dr. Edward Mason described the first experience with gastric bypass for weight loss. This procedure was thought to be much safer than the intestinal bypass because it had minimal if any malabsorption. The main mechanism of action was the restriction of nutrient intake by the creation of a very small gastric pouch which was connected directly to the intestine thereby “bypassing” the vast majority of the stomach and the proximal small intestine. At that time, the gastric bypass was a formidable operation in obese patients. In response, less complicated gastric restrictive procedures were developed. These procedures were known as “gastroplasties” and were very popular in the 1970’s and 1980’s. These procedures partitioned the stomach typically with surgical stapling devices to create small stomach pouches. Although safer and less complex than the gastric bypass, the results were inferior and these procedures declined in popularity. In the mid 1990’s, the gastric bypass was first successfully performed laparoscopically (Figure 2). The ability to now perform gastric bypasses laparoscopically, significantly reduced the operative complications, increased the acceptability of the gastric bypass.
In addition to the introduction of laparoscopy, there was another major advance and that was the introduction of the laparoscopic adjustable gastric band (Figure 1). This relatively simple and safe procedure behaved like a gastroplasty in that it creates a small gastric pouch but did so without staple-partitioning the stomach. The procedure has a very low complication rate. Another beneficial feature of the band is its adjustability. The band can be tightened or loosened in a simple office procedure thereby allowing the band to be uniquely adjusted for each individual patient. Band popularity sky rocketed worldwide but has recently diminished due to inferior results compared to the gastric bypass and also to the introduction of a new procedure known as the sleeve gastrectomy (Figure 3).
The sleeve involves the removal of the outer crescent of the stomach leaving behind a very small stomach remnant that holds only a few ounces. The sleeve has become very attractive for patients wanting good results with less of the risk and complexity of the gastric bypass.