A few surgeons started experimenting with various procedures intended to cause significant weight loss in the 1960s. The medical profession as a whole attacked these surgeons in general. Such "experimental" therapies were thought to be harmful, improper, and nonsensical. Despite this criticism, a variety of surgical techniques have been created and used to help people lose weight during the past 50 years. They have included everything from physically wiring the patient's jaws closed to stuffing a big balloon into the stomach to make room. Other plastic surgery techniques that physically remove fat, such as liposuction, have also been promoted as efficient ways to lose weight. Only a small number of surgeons have endorsed several of these operations, many of which offer little in the way of success. Some deserved little more than a fleeting remark because they were hardly more than passing novelty.
The surgical community accepted other procedures more broadly. These bariatric procedures can be categorized as either restrictive or malabsorptive. While malabsorptive surgeries prevent nutrients from being absorbed by the intestine, restrictive bariatric procedures restrict the amount of food that can be ingested. Both aspects are used to some extent in several methods. Every process type has a unique set of advantages as well as unique challenges.
Also known as the JI Bypass or Intestinal Bypass, the Jejuno-Ileal Bypass
The jejuno-ileal bypass was one of the most frequently carried out bariatric procedures in the 1960s and 1970s. Another name for it was the intestinal bypass. The small intestine was simply cut from its typical length of roughly 18 feet to only about 4 feet during the surgery. No matter how much the person ate, the idea was to reduce food absorption.
The duodenum, jejunum, and ileum are the three sections that make up the small intestine. The initial segment of the small intestine, the duodenum, is only a foot long. The jejunum is the second segment.
roughly makes about half of the small intestine. The remainder of the small bowel, which runs from its midpoint to its terminus, where it empties into the colon, is known as the ileum.
Different nutrients are absorbed by the small intestine's various sections. In the opposite direction, some substances that are absorbed in the jejunum are not absorbed in the ileum. Particularly, several vitamins and bile salts can only be absorbed in the "terminal" ileum, which is the very last section of the small intestine. Armed with this knowledge, surgeons tried to preserve at least a portion of both the jejunum and the terminal ileum when performing any treatment to shorten the small intestine; hence the name of the procedure, jejuno-ileal bypass.
Patients frequently lost a large amount of weight quickly after a JI bypass. This procedure was lauded by many patients as the "cure" for their obesity. However, as time passed, several patients experienced severe adverse effects as a result of this intestinal reconfiguration. Dehydration, kidney stones, uncontrollable diarrhea, anemia, malnutrition, several vitamin deficiencies, even liver failure were among the issues. Eventually, deaths from what became known as the JI bypass "short-gut" syndrome started to be documented.
The idea among doctors and surgeons that obesity was anything but a surgical disease only increased with the rising frequency and severity of significant problems brought on by JI bypass. The majority of the surgical community largely avoided those who really performed bariatric surgery. Even still, many of these early pioneers believed that the solution to the myriad issues with JI bypass lay simply in their capacity to exactly leave behind the proper quantity of each component of the intestine. Arguments regarding the precise length of terminal ileum and jejunum that should be left behind to achieve the desired weight loss while preventing nutritional problems raged for more than ten years.
The JI bypass eventually lost favor by the end of the 1970s and was replaced by slightly safer techniques, carried out on
the stomach and created to only limit the amount of food consumed. It seems sense that these were called gastric restricting surgeries.
Procedures that restrict the stomach
Theodor Billroth, a German surgeon, gained widespread recognition as the pioneer of gastric surgery in the second half of the nineteenth century. He invented many of the procedures still used today to disconnect the small intestine from the stomach and remove various stomach components. There were no drugs that could restrict the stomach's ability to create acid before the mid-1970s, as there are today. As a result, surgery to remove significant portions of the stomach was commonly used to treat stomach ulcers, which were prevalent and frequently serious problems. In those days, almost every surgeon's practice included ulcer surgeries in some capacity. More or less in the same way for more than a century, these techniques have been used to treat stomach cancer in addition to ulcer disease.
It has long been known that many people who undergo gastric surgery report significant weight loss afterward. That was in fact regarded as one of the more severe and unfavorable side effects. Normally, the stomach has room for a quart or more of food and liquid. Naturally, the amount of food a person can eat at any given time will be significantly impacted if a large portion of the stomach is removed or bypassed. A smaller stomach caused serious issues for several individuals just to maintain appropriate nutrition. However, significant gastric surgery was exactly what those who were already morbidly obese needed to lose weight. Finally, as a result of these experiences, surgeons started doing these procedures exclusively to help patients lose weight.
Surgical stapling equipment became accessible in the 1960s and was a significant technological advancement, especially for stomach surgeries. By dividing the stomach and using staples rather than stitches to connect the margins, they were able to complete these procedures more quickly and easily. This provided better control of bleeding and potential infection than more conventional methods, and also facilitated cutting out parts of the stomach faster.
surgical infections thereafter. In the end, staplers were only made to close tissues like the stomach, not to actually divide them. Several of the staples could be removed from the middle of the stapler so that when it was placed across the upper part of the stomach, the device would effectively create two compartments with a small opening between them. Surgeons soon learned to modify these devices to perform a straightforward weight-loss procedure, which became known as "gastric stapling."
The upper portion of the stomach was intentionally made small so that it would only fill up with a very modest meal, which limited the amount of food the patient could eat. Eventually, food moves through the narrow aperture and into the remaining portion of the stomach, where it is digested. Due to the procedure's reasonable success rate and far lower risk than the JI bypass, it was widely accepted among bariatric surgeons.
Although gastric stapling does result in significant weight loss, the effects are short-lived. The gap between the two stomach halves has a tendency to enlarge over time, which is an issue. As a result of the food moving fast from the upper compartment into the bottom compartment, patients can consume ever larger meals. As a result, within a few years, the majority of patients usually gain the weight they lost back. The vertical banded gastroplasty was created as an answer to this issue.
banded vertical gastroplasties
Later, the technique for gastric stapling was changed to help solve the issue of the elongation of the opening between the two portions of the stomach. Instead of running across the stomach, the staple line was more up and down, and the gap between the two parts of the stomach was sealed off by a ring that prevented stretching. To prevent the steel wire in the ring from piercing the stomach wall, the wire was covered in silicone. As soon as this permanent band was in position, it preserved the size of the gap between the two stomach halves. The vertical banded gastroplasty, sometimes known as VBG, is the name given to this technique. It was the most widely used bariatric operation for much of the 1980s.
Although the banded opening could not stretch, the upper stomach pouch often became stretched, allowing patients to eat more, and they gained much of their lost weight back, leading many who performed the VBG to believe they had once again discovered the solution to the problem of morbid obesity. Patients were losing weight rapidly, and the risk seemed to be relatively low. However, upon closer inspection.
nutrition-related issues
As long as the patient ate a balanced diet, the issues of malnutrition, vitamin deficiencies, and anemia could be avoided, but it takes a great deal of effort to undo years of dreadful habits.
The problem is that most of these foods are high in calories yet lack adequate nutritional balance. They are typically short on protein and high in carbohydrates and fat. Since the procedures were so restrictive, many patients switched over to eating things that would go through easily. Eating ice cream and drinking milkshakes or other high-calorie liquids was common.
In addition to having muscle atrophy and hair loss, they had gained back a significant amount of weight.
Roux-en-Y, also known as gastric bypass
The Roux-en-Y gastric bypass, which is frequently used today to treat morbid obesity, was a modification of what is known as a subtotal gastrectomy, in which most of the stomach is removed. This procedure was the vertical banded gastroplasty, which was the darling of the bariatric surgical community from the late 1970s and into the 1980s, but as late failures started to mount up.
The intestine is divided near the beginning of the jejunum to perform a Roux-en-Y gastric bypass. The lower end of the divided intestine is brought up to the small stomach pouch and sutured or stapled to it. This allows food to pass directly into the intestine, bypassing the rest of the stomach. The upper end of the divided intestine is then connected to the lower end to complete the procedure.
Since food is also being directed around the duodenum, which is also bypassed after Roux-en-Y reconstruction of the upper intestinal tract, bile and pancreatic enzymes, which are both added to the intestine in the duodenum, are not readily available to aid in the digestion of fats and carbohydrates until after the food gets down to the point where the two parts of the intestine are rejoined.
The small bowel limb, also known as the bypass limb, is the segment of intestine that extends from the stomach down to where the small intestine is reconnected. It would seem logical that the longer the small bowel limb, or bypass limb, the better, as the pancreatic enzymes and bile enter back into the main stream of the intestine at this point, and only then can they start to digest the food.
The size of the stomach pouch is crucial when performing a Roux-en-Y gastric bypass; if it is too large, the patient can eat excessively and will not lose weight; if it is too small, the patient may struggle to maintain adequate nutrition. However, as with the VBG, it is important to recognize that the stomach is quite stretchable, and with time the pouch is likely to expand. Therefore, in general it is preferable to start out too small rather than too large.
Similar to the stomach stapling procedure, it is common for this opening to stretch over time, resulting in late weight gain. If the surgeon makes the opening between the stomach and the small intestine too large, the food just goes right through, and the patient never feels satisfied.
Another issue that can arise from this new connection between the stomach and intestine is that it is fairly common for the opening to become very narrow, either because of excessive scar tissue or acute inflammation brought on by ulcerations at the site of connection. The latter typically occurs within a few weeks following the surgery, whereas narrowing brought on by scar tissue may not show up for years.
The Roux-en-Y gastric bypass is still the most popular procedure used in bariatric surgery today, despite these and other issues. There have been a few modifications, such as one in which the stomach is only stapled closed and not actually divided, followed by the connection of a Roux-en-Y limb up to the upper gastric segment. As you might expect, the issue with this option is once again the failure of staples, allowing food to pass through.
Another modification involves bringing a loop of the intestine up to the stomach and connecting it to the pouch, avoiding the Roux-en-Y entirely. However, this modification frequently results in a number of complications, including ulcers and chronic abdominal pain as pressure builds up inside the intestinal loop. Generally, these modifications are being performed by only a few surgeons and are not considered mainstream bariatric procedures.
Story of Kathy
Pre-op Kathy, 373 pounds (left).
(Right) Kathy, 145 pounds, 19 months post-op.
I had every major health problem. I was diabetic, had a hiatal hernia, high cholesterol, high blood pressure, sleep apnea, arthritis in my knees and elbows, and more. I took 15 pills a day to survive, and I couldn't even walk up steps. I started at 373 pounds, and I'm 5 feet, 8 inches tall. My doctor told me to get 150 pounds off or I wouldn't see my next birthday. I was in tears. I was about to have my first grandchild, and I didn't know if I would even get to hold her.
I'd say there wasn't a diet I wasn't familiar with; I did Weight Watchers°, TOPS, the cabbage diet, and more. I eventually reached to the point where I'd go on a diet, lose 20 pounds, and no one could even notice; of course, then I'd put back on double.
I looked into gastric bypass on the internet and found that everyone was having complications later on, so everything I read was against it. When I told people, my husband and my doctor were also against it. However, I reasoned that since I was going to die anyhow, what did I have to lose? If I had it, at least I could save my life. I didn't know about the band, but looking back I probably wouldn't have chosen it anyway.
I learned that in order for my insurance to pay for bypass surgery, a doctor had to recommend it. I took my husband, who doesn't speak much English and has a headache problem, to a doctor who speaks fluent Spanish, and while we were there, I asked the doctor about bypass surgery. He said he thought it was a good idea and that I'd be a good candidate. My husband was then more open to the idea.
We submitted to insurance and they denied it; we resubmitted and they said yes; but the obstacle was still insurance. I felt like I knew precisely what was going to happen because I attended three separate doctors' seminars.
I had surgery on December 21, just 10 days before the cutoff date, went home December 22, and went back to work the next day (I work for the phone company, so I didn't really take any time off), and I had to work Christmas Eve and Christmas Day, too, because I would have lost all my holiday pay if I hadn't, and found out they were going to stop paying for it as of the end of the year.
I started exercising the day I got home from the hospital, first by walking around the block a few times, then working up to 2 miles, then up to 10 miles a day. On my lunch break, I work out at Curves®. I never had much of an appetite after the surgery. I ate to stay healthy, not because I was hungry. I had to eat to keep my bones healthy and to keep my hair. I stuck to the liquid diet after the surgery, then went to pureed foods.
I lost 25 pounds the first week after my surgery, then 10 to 15 pounds a week after that, and I think I leveled off about a month ago. I still weigh 145 pounds 19 months after my surgery. I don't actually have much hanging skin, except on the inside of my thighs. Some plastic surgeons claim you cannot get rid of the loose skin without surgery, but that wasn't true for me. I worked out a lot and firmed up.
I had follow-ups with my surgeon every three months, but he said I don't have to go back to him unless I fall under 150 pounds, which happened, so I did see him again. However, he didn't have much to say about my weight. I did meet with a dietician a few times prior to the surgery and in the weeks following.
I don't eat sweets like chocolate and have had several episodes where I felt like I was having a heart attack. If you experience dumping syndrome once, you don't want to experience it again. What I ate ran right through me, and there was nothing I could do to stop it.
I've thrown up a couple of times after my operation, and it's more like foam that comes out. It aches to vomit up. I felt like something was caught in my chest and I couldn't get it to go up or down.
I know other people have had a lot of trouble with the bypass, but I think the difference between me and someone else is that I followed the fitness regimen exactly the proper way. I've always been sociable, but I see people regard me differently.
Bilateral Pancreatic Divert
The biliopancreatic diversion (BPD), a variation of the Roux-en-Y gastric bypass, significantly shortens the functional intestine and combines the restriction of a small pouch with the malabsorption effects of a short intestine. Patients who undergo such operations frequently experience dramatic weight loss, but not surprisingly, they also experience some of the same complications.
The biliopancreatic diversion with duodenal switch (BPD-DS), a similar modification of this operation, involves reducing the size of the stomach by performing what is known as a sleeve gastrectomy, which transforms the stomach into a long tube, and actually removing the remainder of the stomach pouch because it is thought that many of the hormones that cause hunger are produced in this large stomach pouch.
As you might imagine, these extremely complex operations, carried out on extremely obese patients, carry a significant risk of a variety of complications. Both of these procedures are typically reserved for patients who are extremely heavy, with a body mass index (BMI) over 80; a category frequently referred to as "super obese."
Some surgeons have chosen to perform the BPD-DS as two separate operations, the first of which is the sleeve gastrectomy, and the second of which is the small intestine rearrangement, several months later. Many patients tend to lose a significant amount of weight following the creation of a gastric sleeve, and this can significantly reduce the risk of their second procedure. Recently, some surgeons have started using the gastric sloop.
Roux-en-Y Gastric Bypass Results
Weight reduction following a gastric bypass can be 5, 6, or even as much as 10 pounds a week when done properly, making the Roux-en-Y gastric bypass technique and its modifications frequently referred to as the "gold standard" for bariatric treatments.
Even though a patient has spent a lifetime gaining weight, rapid weight loss is very alluring to someone looking for a "quick fix." However, very rapid weight loss is frequently accompanied by serious nutritional problems. What amounts to a crash diet can result in inadequate intake of protein, certain vitamins, and essential nutrients.
Vitamin B-12 is essential for the production of red blood cells, which carry oxygen throughout the body, and is crucial for maintaining normal nerve function. B-12 deficiency, which manifests as anemia, is one of the inherent problems with any procedure that bypasses the majority of the stomach.
Anybody who has a gastric bypass needs to be getting B-i 2 regularly, to avoid anemia as well as serious neurological issues. When the bulk of the stomach is bypassed, patients tend to develop anemia because they have trouble absorbing this essential vitamin even if they are taking in iron-rich foods or iron supplements.
The most serious potential issues with gastric bypass relate to the fact that when the stomach is divided, it necessitates some sort of reconnection to the intestinal tract, and even in the most skilled hands there is always the possibility of a leak. If the liquid contents of the stomach leak out into the abdominal cavity, it will likely result in a serious and occasionally life-threatening infection, especially if the patient has a history of gastrointestinal bleeding.
An incisional hernia is one of the other risks associated with the various bypass and stapling procedures. If the wound doesn't heal completely the edges of the muscle can separate, resulting in a defect in the abdominal wall known as an incisional hernia. This can happen in any patient, but those with diabetes or who smoke cigarettes are at particularly high risk because both conditions interfere with wound healing. Overall, about 20% of patients who undergo ba experience this complication.
Today, bariatric surgery still carries some of the stigma of being too risky, and some have suggested that it is being performed by surgeons more concerned about money than the health and well-being of their patients. As bariatric surgery became a more acceptable treatment option, more and more surgeons began to perform these procedures. Many have been forced to reconsider that decision after experiencing one or more serious operative complications as well as rising liability insurance premiums.