History and Introduction to Weight Loss Surgery

Bariatric surgery today can result in weight loss by causing restriction of intake of food or malabsorption of food. Many different operations have been developed over the past 50 years and there are multiple options for patients to consider before under taking bariatric surgery. Understanding the history of weight loss surgery and what procedures have been tried and which have failed and why we think they failed is a key to making an informed choice. Every Bariatric Weight Loss Surgery has advantages and disadvantages, successes and failures, so familiarize yourself with the history of bariatric surgery and ask questions of your surgeon.

Open weight loss surgery began slowly in the 1950’s with the Intestinal Bypass which caused weight loss purely by the malabsorption of food. The surgery bypassed all but 12-14 inches of the small bowel which was approximately 30 feet long, and the stomach was left unchanged. The procedure was abandoned in the 1970’s due to serious nutritional problems which developed in some patients such as liver failure. It has been recommended that any patient who underwent an Intestinal Bypass should have the surgery reversed or converted to another bariatric procedure to prevent these potentially serious complications.

In the 1970’s the Vertical Banded Gastroplasty (VBG) was introduced by Dr Ed Mason in Iowa. This procedure caused weight loss by purely restricting the intake of food in the stomach, and nothing was done to the small bowel. The stomach was reduced from approximately two quarts to one ounce (30cc) with a surgical stapler and the outlet to drain the small pouch was reduced to ½ inch (one cc) with a plastic band wrapped around the outlet to keep it from stretching. The small pouch and rigid outlet resulted in a lot of vomiting, and acid reflux, and the average weight loss was only around 50% of the patients Excess Weight. Long term around 50% of patients had revisions, conversions or reversals of their surgery due to complications or weight loss failure. The VBG has fallen out of favor in the United States due to these problems and has been replaced by
the Laparoscopic Adjustable Gastric Band or Sleeve Gastrectomy.

The Roux en Y Gastric Bypass (RNY) began to be widely adopted for weight loss in approximately 1982. It combined gastric restriction to limit food intake with some limited malabsorption of food in the small bowel. The stomach was reduced to a one ounce pouch with a narrow opening, but a band wasn’t utilized to permanently restrict the opening, and the distal stomach and proximal small bowel were bypassed for approximately 5 feet. This procedure resulted in greater weight loss and sustained weight loss compared to the VBG, and ultimately became the most popular weight loss surgery in the United States. The Gastric Bypass averaged 75% Excess Weight Loss and had a 90% success rate after 5 years in most studies.Weight loss surgery was unpopular with many physicians due to the problems seen with the Intestinal Bypass in the 1980’s and 1990’s and only around 12,000 procedures were performed each year. Two events changed that view: (1) In 1992 the National Institutes of Health (NIH) held a Consensus Conference of medical experts to evaluate bariatric surgery and its role in treating Morbid Obesity. The NIH found there were two procedures which they felt were safe and effective for treating morbid obesity and they were the Vertical Banded Gastroplasty and the Roux Gastric Bypass. They then set the standard to qualify for surgery of being 100 pounds over an ideal body weight or having a Body Mass Index (BMI) of 40 without health issues or a BMI between 35- 39 if associated with medical problems due to being overweight. These same criteria persist today. This endorsement by the NIH and establishment of clear standards convinced a number of physicians to begin recommending weight loss surgery to their patients. (2) In 1994 the first Laparoscopic Gastric Bypass was first performed and the laparoscopic approach was quickly adopted for the Vertical Banded Gastroplasty. The Laparoscopic Adjustable Gastric Band which was designed specifically to be inserted by a laparoscopic surgical approach and replace the VBG was initially introduced in Europe and then approved for a Clinical Trial in the United States in 1998. Suddenly the laparoscopic approach and less invasive surgery was accepted by the public and the
number of patients undergoing surgery exploded to over 200,000 people a year.

The Duodenal Switch procedure was also introduced in the United States in the 1990’s for weight loss by a small number of surgeons (less than 5%), but has never been widely accepted by patients or surgeons due to its significant risk of malnutrition and frequent watery diarrhea. It combined the Gastric Bypass and Intestinal Bypass procedures with
both a reduction in stomach volume and a radical bypass of the small bowel, bypassing all but 3-5 feet of the 30 foot intestine. The operation was used more often in super obese patients with a BMI greater than 60; often weighing 600-800 pounds, due to its ability to create long term malabsorption and greater weight loss than a Gastric Bypass. The Gastric Sleeve procedure came out of this operation by accident. A group of surgeons began breaking the Duodenal Switch operation into two separate operations performed 6 months apart in order to reduce the operating time and risk associated with this radical operation. The stomach size was first reduced by performing the Gastric Sleeve
procedure which would cause patients to lose around 100 pounds in 6 months and then the second operation would be performed to bypass the small bowel and reattach the gastric sleeve to the distal small bowel to form the completed Duodenal Switch. Some patients refused to undergo the second stage of the operation because they were happy with their initial weight loss from the Gastric Sleeve. Surgeons then began using the
Gastric Sleeve in smaller BMI patients with BMI’s in the 40-50 range and the weight loss was significant. The Gastric Sleeve has now been recognized by several surgical societies as acceptable as a stand alone weight loss operation. The primary problem with the Gastric Sleeve and any purely restrictive weight loss operation (VBG, Band, Sleeve) is there is limited long term information, and will the weight loss persist long term.

After introduction of Laparoscopic Bariatric Weight Loss Surgery many more patients were uncomfortable with the stapling of the stomach and rerouting of the small bowel associated with the Gastric Bypass and have sought out a simpler procedure by going back to considering a purely restrictive weight loss procedure like the Laparoscopic Adjustable Gastric Bands (Lap Band© and Realize Band©) or Sleeve Gastrectomy; accepting less weight loss in exchange for what they believe is a safer procedure. Currently approximately 50 % of weight loss surgery in the United States
is Gastric Bypass and 50% are Laparoscopic Adjustable Gastric Bands or Sleeve Gastrectomies.

Today all bariatric operations can be performed by an open or laparoscopic incision, depending on the experience of the surgeon, the patient’s health history, and the type surgery being performed.
Despite the overwhelming evidence that Bariatric Weight Loss Surgery improves patient health, reduces medical expense and prolongs life expectancy most insurance companies refuse to pay for Bariatric Surgery. The number of patients undergoing weight loss surgery is actually decreasing due to the insurance roadblock.