Brief History of Bariatric Surgery

Over the past millennia, humans have transitioned from a nomadic hunter-gatherer lifestyle, consuming foods high in protein, to that of a farmer consuming large amounts of processed simple sugars.

Early humans, during periods of famine, developed “thrifty” genes that conserved energy. These genes, in the present time of abundance, lead to obesity with insulin resistance and metabolic syndrome (impaired glucose tolerance, type 2 diabetes mellitus, hypertension, atherosclerosis, dyslipidemia, and fat accumulation in the liver). In the last century, with the development of high-calorie fast food containing high levels of carbohydrates, saturated fats, and salt, metabolic diseases have become increasingly noticeable.

With the advent of computers and a sedentary lifestyle, obesity has become the main form of nutritional disorder worldwide.

With the increase in obesity in the 1960s and the accumulated experience of unsuccessful conservative treatment of severe obesity, bariatric operations were developed for patients with a body mass index (BMI) > 40 kg/m² (or > 35 kg/m² with comorbidities). These operations led to significant weight loss; however, the main goal was to maintain this condition.

The term “morbid” was applied to obesity associated with a serious, progressive, debilitating disease. Osteoarthritis, limited mobility, sleep apnea, hernias, certain types of cancer, stress urinary incontinence in women, infertility, and psychosocial and economic problems are associated with the “epidemic” of obesity.

In the late 1960s, Edward Mason performed bypass of 90% of the stomach with formation of a loop gastrojejunostomy. This operation included both restrictive and malabsorptive components. Weight loss led to the disappearance of comorbidities and seemed to be safe. However, in the postoperative period, increased pressure in the anastomotic area was observed, as well as reflux of intestinal contents into the gastric stump, with a subsequent possibility of failure at this site.

Subsequently, Mason’s gastric bypass was modified into the Roux-en-Y (RYGB) configuration and began to be widely performed. This resulted in approximately a 70% reduction in body weight over 5 years. However, later complications began to occur, including early anastomotic failure, bleeding, internal strangulated hernias, and marginal ulcers of the anastomosis. Salicylates and smoking were prohibited.

Dumping syndrome sometimes follows RYGB due to the rapid entry of sugar-containing foods into the small intestine and may beneficially prevent patients from consuming sweets. Nevertheless, over time, patients may resume consumption of sweets, which may provoke dumping syndrome, which patients may “treat” by consuming simple sugars with subsequent weight regain.

In the 1990s, a gastric band began to be placed around the proximal part of the stomach to restrict food intake. It is a band connected by a tube to a subcutaneous reservoir. Saline is added to or removed from the reservoir to control the size of the band, which requires frequent visits to monitor weight loss.

The original perigastric dissection technique (which was sometimes accompanied by accidental damage or slippage of the gastric wall) was improved by the pars flaccida technique, which caused minimal trauma to the gastric wall.

The average weight loss in patients who had undergone banding 5 years earlier was about 45%, but later complications included erosion at the site of contact between the band and the gastric wall, band slippage, and problems with the reservoir.

To avoid complications of jejunal bypass due to the presence of a blind loop, Nicola Scopinaro developed biliopancreatic diversion (BPD) in the late 1970s.

This malabsorptive procedure resulted in approximately 75% weight loss and excellent control of type 2 diabetes mellitus. Starch and fats were absorbed in the distal 50 cm of the ileum.

However, BPD had episodic complications in the form of hypoalbuminemia and deficiencies of vitamins and minerals, which were difficult to overcome despite supplementation.

BPD was modified into the duodenal switch in the 1990s, providing long-term weight loss of up to 70% with a low risk of complications.

In the duodenal switch (DS), sleeve gastrectomy is performed, and food enters the portion of the stomach remaining along the lesser curvature, which limits food intake for approximately 9 months.

The small intestine is transected 250 cm proximal to the ileocecal valve and anastomosed to the separated first part of the duodenum.

The biliopancreatic limb of the small intestine is anastomosed to the ileum approximately 100 cm proximal to the ileocecal valve.

Malabsorption maintains weight loss. There are issues with frequent stools and unpleasant odor of flatus, which can be controlled.

It was established that in many patients with obesity and a high risk level, the duodenal switch operation should be performed in stages.

Accordingly, starting from 2001, only sleeve gastrectomy (gastric sleeve resection) was performed as the first stage; however, it was found that many patients had satisfactory weight loss and did not require a second stage.

Thus, sleeve gastrectomy is usually performed as a standalone operation (with the formation of a narrower gastric tube than in the duodenal switch).

The average weight loss over 5 years is approximately 60% (almost the same as with gastric bypass), but weight regain often occurs.

With resection of the gastric fundus and dissection in the area of the angle of His and the left crus during this operation, a serious complication may occur in the form of staple line leakage, which requires intervention, drainage, stent placement, and intravenous nutrition.

Leakage often causes stress in the patient but is successfully treated.

Gastroesophageal reflux and Barrett’s esophagus may develop in one-third of patients after sleeve gastrectomy. Patients with weight regain after sleeve gastrectomy were re-treated by converting this operation into a duodenal switch, gastric bypass, or, now often, a mini-gastric bypass.

SADI-S is a simplified single-loop variant of the duodenal switch.

In SADI-S, there is a risk of leakage in the upper part of the gastric tube, similar to sleeve gastrectomy; this procedure requires low mobilization of the duodenum, as well as more precise measurement of the intestine to prevent hypoproteinemia.

Nevertheless, the reduction in comorbidities was excellent. This is a longer operation than mini-gastric bypass (MGB).

MGB is a safe and fast procedure that has become the second most commonly performed bypass operation, and its number is continuously increasing worldwide.

MGB was first performed by Rutledge in 1997 in the USA to reconstruct the stomach in a case of a gunshot injury.

The gastric tube is created by resecting the stomach horizontally below the “crow’s foot,” and then vertically, as in sleeve gastrectomy.

The long gastric tube is anastomosed to a loop of the jejunum approximately 200 cm distal to the ligament of Treitz (depending on BMI).

After the work of Rutledge, in 2002 Carbajo and Garciacaballero in Spain (after performing RYGB for more than 10 years) initiated the OAGB variant (One-Anastomosis Gastric Bypass) of MGB (BAGUA — Bypass Gástrico de Una Anastomosis) to prevent potential gastroesophageal reflux.

However, after MGB with a low-pressure gastric tube, gastroesophageal reflux occurs in less than 1% of cases.

MGB and OAGB are associated with excellent reduction in manifestations of comorbidities, good quality of life, and sustained long-term weight loss.