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Faria
GR.
A
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bariatric
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Biomed.
J.
2017.
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Rostrum
A
brief
history
of
bariatric
surgery
Gil
R.
Fariaa,b,∗
aDepartment
of
Surgery,
Unidade
de
Investigac¸
ão
em
Cirurgia
Digestiva
e
Metabólica,
Centro
Hospitalar
do
Porto,
Hospital
de
Santo
António,
Porto,
Portugal
bCenter
for
Health
Technology
and
Services
Research
(CINTESIS),
Instituto
de
Ciências
Biomédicas
de
Abel
Salazar,
Porto,
Portugal
a
r
t
i
c
l
e
i
n
f
o
Article
history:
Received
22
April
2016
Accepted
19
January
2017
Available
online
xxx
Keywords:
Bariatric
surgery
History
of
medicine
Gastric
bypass
Gastric
sleeve
Mini
gastric
bypass
a
b
s
t
r
a
c
t
Obesity
has
been
a
problem
since
medieval
times,
but
only
in
the
latter
20
years
it
has
been
recognized
as
a
worldwide
epidemic.
Treating
obesity
is
challenging
and
difficult,
but
surgery
has
led
to
an
increased
success
and
novel
insights
on
the
pathophysiology
of
obesity.
Several
surgical
techniques
have
been
developed
during
the
last
50
years
and
the
advent
of
laparoscopic
surgery
has
increased
its
safety,
efficacy
and
demand
from
the
population.
Nowadays,
the
ever
increasing
and
successful
use
of
novel
techniques
have
been
responsible
for
several
changes
in
the
established
treatment
paradigms.
©
2017
PBJ-Associac¸ ˜
ao
Porto
Biomedical/Porto
Biomedical
Society.
Published
by
Elsevier
Espa˜
na,
S.L.U.
This
is
an
open
access
article
under
the
CC
BY-NC-ND
license
(http://creativecommons.org/
licenses/by-nc-nd/4.0/).
Historical
reports
claim
that
the
first
bariatric
surgery
was
per-
formed
in
Spain,
in
the
10th
century.
D.
Sancho,
king
of
Leon
was
reported
to
be
such
an
obese
man
that
he
could
not
walk,
ride
a
horse
or
pick
up
a
sword.
This
led
him
to
lose
his
throne.
He
was
then
escorted
by
his
grandmother
to
Cordoba
to
be
treated
by
the
famous
Jewish
doctor
Hasdai
Ibn
Shaprut.
He
sutured
the
kings’
lips
who
could
only
be
fed
on
a
liquid
diet
through
a
straw,
consist-
ing
of
teriaca:
a
mixture
of
several
herbs,
including
opium,
whose
side
effects
stimulated
weight
loss.
King
Sancho
lost
half
his
weight,
returned
to
Leon
in
his
horse
and
regained
his
throne! 1,2
Even
though
specific
weight
loss
interventions
are
sparsely
reported
throughout
the
literature
in
the
second
half
of
the
20th
century,
they
remained
in
obscurity
until
the
1990s.
Indeed,
it
was
only
when
the
obesity
epidemics
got
finally
recognized
that
the
medical
community
started
considering
surgical
approaches
to
tackle
it.3,4
The
first
metabolic
surgery
is
attributed
to
Kremen
in
1954:
the
jejuno-ileal
bypass.5It
consisted
of
an
anastomosis
between
the
proximal
jejunum
and
distal
ileum,
bypassing
much
of
the
small
intestine
and
was
devised
to
treat
severe
forms
of
dyslipide-
mia.
This
was
a
surgery
with
major
metabolic
consequences,
such
that
most
patients
suffered
from
severe
diarrhea
and
dehydration
and
thus,
it
was
not
yet
ready
for
mainstream
adoption.
Henry
Buchwald,
later
demonstrated
that
ileal
bypass
(with
a
jejuno-colic
∗Correspondence
address:
Center
for
Health
Technology
and
Services
Research
(CINTESIS),
Centro
Hospitalar
do
Porto,
Hospital
de
Santo
António,
Departamento
de
Cirurgia,
Largo
do
Prof.
Abel
Salazar,
4099-001
Porto,
Portugal.
E-mail
address:
gilrfaria@gmail.com
anastomosis)
had,
indeed
an
effect
on
lowering
the
lipid
levels
in
patients
with
familiar
hypercholesterolemia
and
that
this
effect
was
sustainable
for
many
years.6,7 Several
modifications
of
these
intestinal
bypass
procedures
were
reported
in
the
1960s
and
70s,
but
none
of
them
gained
widespread
acceptance.
In
1966,
Dr.
Mason,
a
surgeon
from
the
University
of
Iowa,
noting
that
patients
with
sub-total
gastrectomy
for
cancer
lost
a
consid-
erable
amount
of
weight,
proposed
the
first
“bariatric
surgery”:
the
first
gastric
bypass.8Initially
it
consisted
of
an
horizontal
gas-
tric
transection
with
a
loop
ileostomy,
but
it
was
later
optimized
to
smaller
gastric
pouches
and
stoma
sizes.9Due
to
severe
bile
reflux,
the
reconstruction
was
proposed
with
a
“Roux-en-Y”
loop,10
which
diverts
the
bile
from
the
stomach
and
esophagus
and
has
become
the
surgical
standard.
Compared
to
jejuno-ileal
bypass,
gastric
bypass
procedures
resulted
in
less
diarrhea,
kidney
stones
and
gallstones
and
improvement
in
liver
fat
content.10
Several
modifications
to
this
technique
were
proposed
to
improve
weight
loss,
such
as
the
Fobi-Capella
banded
gastric
bypass,
which
consisted
in
the
application
of
a
ring
to
the
gas-
tric
pouch,
in
order
to
limit
its
enlargement
and
possible
weight
regain.11,12 Pouch
sizes
had
been
correlated
to
weight
loss.
Accord-
ing
to
Laplace’s
law,
the
larger
the
pouch,
the
larger
the
wall
tension,
which
would
lead
to
further
dilatation.
Thus,
small
pouch
sizes
(<30
ml)
have
become
the
norm.3
In
1994,
the
first
laparoscopic
gastric
bypass
was
performed
by
Alan
Wittgrove13 and
the
exponential
growth
of
bariatric
and
metabolic
surgery
had
definitely
started.
It
is
estimated
that
in
2011,
more
than
340,000
procedures
have
been
performed
worldwide.14 Currently,
the
most
common
technique
involves
the
creation
of
a
small
gastric
pouch,
a
biliary
limb
of
70
cm
and
a
Roux
http://dx.doi.org/10.1016/j.pbj.2017.01.008
2444-8664/©
2017
PBJ-Associac¸ ˜
ao
Porto
Biomedical/Porto
Biomedical
Society.
Published
by
Elsevier
Espa˜
na,
S.L.U.
This
is
an
open
access
article
under
the
CC
BY-NC-ND
license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
Please
cite
this
article
in
press
as:
Faria
GR.
A
brief
history
of
bariatric
surgery.
Porto
Biomed.
J.
2017.
http://dx.doi.org/10.1016/j.pbj.2017.01.008
ARTICLE IN PRESS
G Model
PBJ-59;
No.
of
Pages
3
2
G.R.
Faria
/
Porto
Biomed.
J.
2017;xxx(xx):xxx–xxx
limb
of
150
cm,
although
several
surgeons
have
developed
slight
adaptations
to
the
technique
and
limb
lengths.
Laparoscopic
Roux-en-Y
gastric
bypass
is
a
technically
chal-
lenging
surgery
with
a
steep
learning
curve
and
with
potential
leaks
at
2
anastomosis.
In
an
attempt
to
make
it
simpler
and
safer,
Rutledge
developed
the
Mini-Gastric
Bypass15 (or
omega-
loop
or
single-anastomosis
gastric
bypass),
consisting
of
a
longer
gastric
pouch
and
an
antecolic
loop
gastrojejunostomy
150–200
cm
distal
to
the
angle
of
Treitz.
His
first
surgery
was
in
1997
and
although
Rutledge
published
his
experience
with
thousands
of
patients,16 for
several
years
this
technique
has
suffered
the
criticisms
of
biliary
reflux
and
risk
of
malignancy.17 Increasing
experience
with
this
technique
worldwide
has
reduced
the
con-
cerns
and
in
the
latter
years
it
has
gained
wide
acceptance
among
many
surgeons.18,19 Its
results
are
reported
to
be
even
supe-
rior
to
RYGB,
due
to
its
longer
biliary
limb
and
some
degree
of
malabsorption.20,21
Purely
restrictive
procedures
were
also
developed
as
an
alter-
native
to
gastric
bypass.
These
techniques
were
thought
to
have
less
surgical
morbidity
and
mortality
and
to
be
simpler
to
per-
form.
However,
patients
need
to
be
highly
motivated,
as
the
surgical
result
is
dependent
on
a
mechanism
of
early
satiety.
If
the
patients
consume
liquid
or
soft,
energetically
dense
foods,
distention
of
the
gastric
fundus
does
not
occur
and
patients
do
not
achieve
an
early
satiety.
As
early
as
1977,
Rodgers
et
al.
reported
on
their
experience
with
17
cases
of
jaw
wiring.
The
early
weight
loss
was
comparable
to
gastric
bypass
procedures,
however
patients
regained
weight
after
the
wires
were
removed.22
The
first
restrictive
procedure
on
the
stomach
consisted
of
a
“Nissen-type”
gastric
wrap,
proposed
by
Wilkinson.23 Since
then,
several
gastroplasties
had
been
proposed.
The
most
accepted
pro-
cedure
was
the
vertical
banded
gastroplasty,
proposed
by
Mason
in
1982.24 It
combined
a
vertical
stapled
gastroplasty
with
a
banded
outlet.
The
same
principle
was
developed
by
putting
a
band
around
the
stomach
and
thus
creating
a
narrow
passage
from
the
proxi-
mal
to
the
distal
stomach.
The
great
improvement
with
the
gastric
band
occurred
in
1986,
when
Kuzmak25 allowed
the
band
to
be
adjusted
without
the
need
for
further
surgical
explorations.
There
was
an
exponential
increase
in
the
number
of
surgeries
performed
after
the
introduction
of
the
laparoscopic
technique.
Although
the
first
report
dates
back
to
1993
by
Forsell,26 the
first
laparoscopic
gastric
band
was
placed
by
Cadière
in
1992.27 It
was
an
easy,
fast,
reproducible
technique
with
low
perioperative
morbidity,
almost
abandoned
in
the
latter
years
due
to
long-term
complications
and
failure
in
weight
loss.
On
the
other
hand,
some
surgeons
believed
that
malabsorption
was
required
for
successful
weight
loss.
Due
to
the
complications
associated
with
jejuno-ileal
bypasses
(diarrhea,
liver
failure
and
severe
dehydration),
Scopinaro
proposed
a
significant
change
to
the
technique.
After
initial
studies
in
dogs,
starting
in
197628 he
later
published
the
experience
on
human
subjects
that
underwent
bilio-
pancreatic
diversion
(still
called
the
Scopinaro
procedure).29 The
surgical
technique
included
a
distal
gastrectomy
with
a
long
Roux
limb
and
a
short
(50
cm)
common
channel.
Scopinaro
reported
weight
loss
greater
than
79%
maintained
up
to
25
years,30 because
patients
absorption
capacity
was
limited
to
∼1250
kcal/day.
He
also
reported
a
low
complication
rate,
mostly
with
anemia,
protein
mal-
nutrition
and
stomal
ulceration.
However,
Scopinaro
results
were
not
replicated
elsewhere
and
several
modifications
to
his
technique
were
proposed.
The
most
accepted
of
this
alternative
is
Duodenal
Switch,
reported
by
Marceau31 and
Hess.32 The
changes
included
substituting
the
distal
gastrectomy
for
a
vertical
(sleeve)
gas-
trectomy,
thus
preserving
vagal
innervation
and
pyloric
function.
Then
proceeding
with
a
duodeno-ileal
anastomosis
at
100
cm
from
the
ileo-cecal
valve
(elongating
the
common
alimentary
channel).
This
alternative
technique
of
bilio-pancreatic
diversion
yielded
the
same
weight
loss
with
a
lower
complication
rate.31
Biliopancreatic
diversions
are
very
complex
surgeries
that
still
remain
a
challenge
even
to
the
most
experienced
laparoscopic
sur-
geons.
For
this
reason,
Gagner
proposed
that
it
could
be
done
as
a
staged
procedure,
starting
with
a
vertical
gastrectomy
(sleeve)
and
proceeding
with
the
duodenal
switch.33 The
challenge
of
laparo-
scopic
surgery
in
super
superobese
patients
(BMI
>
60
kg/m2)
had
led
to
the
proposal
of
a
staged
procedure
in
which
sleeve
gas-
trectomy
would
also
be
the
first
part34 of
a
gastric
bypass.
The
observation
that
these
patients
lost
a
significant
amount
of
excess
weight
(56%),
and
the
previous
experience
in
the
UK
with
the
“Magenstrasse
and
Mill”
operation35 (a
vertical
gastric
partitioning
without
gastric
resection,
with
a
small
curvature
centered
sleeve),
led
some
authors
to
propose
sleeve
gastrectomy
as
a
stand-alone
surgery
for
the
treatment
of
obesity.
Sleeve
gastrectomy
allowed
for
a
significant
weight
loss
with
low
perioperative
morbidity,
maintained
digestive
continuity
and
was
easy
converting
to
other
bariatric
surgeries.36 This
surgery
has
proven
to
be
safe
(even
if
sleeve
fistulas
are
harder
to
treat,
due
to
the
high-pressure
system
in
the
gastric
reservoir)
and
although
more
long-term
studies
are
required,
it
has
so
far
resisted
the
test
of
time
and
the
concerns
about
pouch
dilatation.37–39
As
we
have
seen,
bariatric
surgery
has
come
a
long
way
since
the
first
jejuno-ileal
bypasses,
and
bariatric
operations
have
led
the
way
to
a
more
thorough
knowledge
of
digestive
physiology.
The
growth
of
laparoscopic
surgery
with
its
reduced
complications,
shorter
hospital
stay,
faster
recovery,
less
morbidity
and
improved
results
has
led
to
an
ever
increasing
patient
demand.3
Disclosures
The
author
has
nothing
to
disclose.
Conflicts
of
interest
The
author
has
no
conflicts
of
interest
to
disclose.
Funding
There
were
no
external
sources
of
funding
for
this
manuscript.
References
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this
article
in
press
as:
Faria
GR.
A
brief
history
of
bariatric
surgery.
Porto
Biomed.
J.
2017.
http://dx.doi.org/10.1016/j.pbj.2017.01.008
ARTICLE IN PRESS
G Model
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No.
of
Pages
3
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Faria
/
Porto
Biomed.
J.
2017;xxx(xx):xxx–xxx
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