The history of weight loss surgery has been one of trial and error. To the credit and expertise of many dedicated surgeons, anesthesiologists, nurses, and nutritionists, we have learned from prior mistakes and now can provide safe and effective operative procedures. A snapshot of this evolution is described below.
Initial Intestinal Bypasses
The concept of intestinal bypass in the treatment of morbid obesity was first proposed by Kremen and Lineer in 1954. They described dramatic weight loss in patients who had undergone extensive small bowel resection due to poor blood supply to the intestines.
The first operation done intentionally to induce weight loss for obesity was by Payne in 1963. A near complete bypass of the small bowel was performed in 10 morbidly obese patients.
All patients developed marked diarrhea and lost a dramatic amount of weight. Multiple metabolic, fluid, and electrolyte problems were encountered. This led to early reversal of the bypass. Following reestablishment of normal anatomy, all 10 patients rapidly regained weight to their preoperative level. Because of this poor experience, the procedure was abandoned.
Six years later, Payne revised his operation to an end-to-side jejunoileostomy beginning the new era of intestinal bypass procedures. Over the next 20 to 25 years, multiple modifications of this procedure were published in the literature with good success in overall weight loss and maintenance of weight loss.
Up to 90 percent of the small intestine was routinely bypassed. The weight loss occurred because of poor food absorption and diarrhea.
Severe complications of fluid and electrolyte imbalances (in particular potassium, calcium, and magnesium), vitamin deficiencies (especially vitamin B-12, vitamin A, and vitamin E) and fatty infiltration of the liver, some with cirrhosis and liver failure were encountered. Low blood proteins, kidney stones, polyarthritis, bone demineralization, and migratory arthralgia were also diagnosed.
Due to these severe complications, most of the early intestinal bypass procedures have been reversed in recent years and today the procedure is no longer performed.
Developing Today’s Procedures
The disappointing clinical experience with intestinal bypass surgery led to consideration of gastric restrictive or bypass procedures. The mechanism of weight loss would be decreased dietary intake and delayed gastric emptying rather than malabsorption and diarrhea. In 1967, Mason and Ito published results of a gastric bypass procedure whereby a loop of small bowel was sewn to the side of a small gastric pouch. This procedure was revised by Pories and Flinkinger into what is now called a Roux-en-Y Gastric Bypass Procedure. In 1982, Mason proposed a Vertical Banded Gastroplasty using again a small stomach pouch with a circumferential Marlex band around the outlet. The latter two procedures have been, until recent years, the standard surgical approaches.
An extensive outcome literature has been collected since 1982 utilizing the Roux-en-Y Gastric Bypass (RYGBP), and the Vertical Banded Gastroplasty (VBG), relevant to actual weight loss. A review of the published literature suggests that approximately 85 percent of patients achieve a satisfactory result with loss of at least 40 to 50 percent of their excess weight following VBG.
Of some recent concern, however, is the report by Balsinger of 10 or more years follow up after VBG. They found only 26 percent of 71 patients maintained a weight loss of at least 50 percent of their excess weight and 17 percent required reoperation with conversion to a roux-en-Y gastric bypass. They felt this Mayo Clinic experience demonstrated the VBG to not be an effective, durable bariatric operation and discouraged it use. On the other hand, approximately 60 to 70 percent of excess weight loss has been reported following RYGBP. Long-term maintenance of that weight loss has been observed to extend to over 14 years by several investigators. Morbidly obese patients with this degree of weight loss are therefore converted from morbid obesity to just being overweight. They no longer are greater than twice their ideal body weight or 100 pounds over their ideal body weight.
Associated illnesses improve rapidly after bypass including high blood pressure (drugs to lower blood pressure can usually be discontinued), sleep apnea and shortness of breath (CPAP can usually be discontinued), and diabetes mellitus (insulin therapy can be reduced or discontinued). Arthritis, however, shows less dramatic improvement.
It is postulated that this degree of weight loss and improvement in associated diseases will result in improved survival and decreased morbidity. No long-term studies have been completed, however, to document such a beneficial clinical effect. Many patients return to some form of employment. Both operative procedures can occasionally be complicated by suture breakdown, anastomotic leaks, scaring and narrowing of the stomas, bezoar formation, indigestion, esophagitis, gastritis, occasional nutrient deficiencies, and failure -- either with excessive or, more commonly, inadequate weight loss.
