THE STORY OF WEIGHT LOSS SURGERY
Gastric Bypass History and Development
Weight loss surgery was introduced in the United States in the 1960's. The gastric bypass was based on the weight loss observed among patients undergoing partial stomach removal for ulcers. Over several decades, the gastric bypass has been modified into its current form, using a Roux-en-Y limb of intestine (RYGBP).
The Roux-en-Y Gastric Bypass – often called gastric bypass – is considered the ‘gold standard’ of weight loss surgery and is the most commonly performed bariatric procedure worldwide.
There are two components to the procedure. First, a small stomach pouch, approximately one ounce or 30 milliliters in volume, is created by dividing the top of the stomach from the rest of the stomach. Next, the first portion of the small intestine is divided, and the bottom end of the divided small intestine is brought up and connected to the newly created small stomach pouch. The procedure is completed by connecting the top portion of the divided small intestine to the small intestine further down so that the stomach acids and digestive enzymes from the bypassed stomach and first portion of small intestine will eventually mix with the food. The gastric bypass works by several mechanisms. First, similar to most bariatric procedures, the newly created stomach pouch is considerably smaller and facilitates significantly smaller meals, which translates into less calories consumed. Additionally, because there is less digestion of food by the smaller stomach pouch, and there is a segment of small intestine that would normally absorb calories as well as nutrients that no longer has food going through it, there is probably to some degree less absorption of calories and nutrients. Most importantly, the rerouting of the food stream produces changes in gut hormones that promote satiety, suppress hunger, and reverse one of the primary mechanisms by which obesity induces type 2 diabetes
Development of the Lap Band®
The LAP-BAND® System was approved by the FDA in June 2001 for use in weight reduction for severely obese adults with a Body Mass Index (BMI) of 40 or more, or for adults with a BMI of at least 35 plus at least one severe obesity related health condition, such as Type 2 diabetes, hypertension and asthma.The name "lapband®" originated from the surgical technique used, laparoscopic, and the name of the implanted medical device, gastric band.
The common explanation of how this device works is that with the smaller stomach pouch, eating just a small amount of food will satisfy hunger and promote the feeling of fullness. The feeling of fullness depends upon the size of the opening between the pouch and the remainder of the stomach created by the gastric band. The size of the stomach opening can be adjusted by filling the band with sterile saline, which is injected through a port placed under the skin. Reducing the size of the opening is done gradually over time with repeated adjustments or “fills.” The notion that the band is a restrictive procedure (works by restricting how much food can be consumed per meal and by restricting the emptying of the food through the band) has been challenged by studies that show the food passes rather quickly through the band, and that absence of hunger or feeling of being satisfied was not related to food remaining in the pouch above the band. What is known is that there is no malabsorption; the food is digested and absorbed as it would be normally. The clinical impact of the band seems to be that it reduces hunger, which helps the patients to decrease the amount of calories that are consumed.
Sleeve Gastrectomy Development
The history of the sleeve gastrectomy is more an evolution of prior procedures than a discrete timeline of development of a single procedure. The sleeve gastrectomy has evolved from an open duodenal switch procedure to an open sleeve gastrectomy to a laparoscopic sleeve gastrectomy. The earliest experience was in 2001 to 2003 in higher risk patients with super-morbid obesity as a safer staged procedure but this quickly developed into a single-stage option for lower BMI patients. The reason this procedure is safer in higher BMI patients is because the lack of an intestinal bypass reduces complication risk associated with gastric bypass surgery.
This procedure works by several mechanisms. First, the new stomach pouch holds a considerably smaller volume than the normal stomach and helps to significantly reduce the amount of food (and thus calories) that can be consumed. The greater impact, however, seems to be the effect the surgery has on gut hormones that impact a number of factors including hunger, satiety, and blood sugar control. Short term studies show that the sleeve is as effective as the roux-en-Y gastric bypass in terms of weight loss and improvement or remission of diabetes. There is also evidence that suggest the sleeve, similar to the gastric bypass, is effective in improving type 2 diabetes independent of the weight loss. The complication rates of the sleeve fall between those of the adjustable gastric band and the roux-en-y gastric bypass
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Chapman A, Game P, O'Brien P, Maddern G, Kiroff G, Foster B, Ham J. Executive summary: Laparoscopic adjustable gastric banding for the treatment of obesity: Update and re-appraisal. Australian Safety and Efficacy Register of New Interventional Procedures-Surgical (ASERNIP-S) ReportNo. 31, Second Edition. Adelaide, South Australia: ASERNIP-S, June 2002. (Laparoscopic adjustable gastric banding surgery, like the LAP-BAND surgery, is associated with a mean short-term mortality rate of around 0.05% compared to 0.50% for Gastric Bypass and 0.31% for Vertical BandedGastroplasty.)ii Parikh MS, Shen R, Weiner M, Siegel N, Ren CJ. Laparoscopic bariatric surgery in super-obese patients (BMI>50) is safe and effective: a review of332 patients. Obes Surg. 2005 Jun-Jul;15(6):858-63.iii Chapman AE, Kiroff G, Game P, Foster B, O'Brien P, Ham J, Maddern GJ. Laparoscopic adjustable gastric banding in the treatment of obesity: asystematic literature review. Surgery 2004;135:326-351.iv O'Brien P, Dixon J, LAP-BAND: Outcomes and Results, J of Laparoend & Adv Surg Techniques, 13(4), 2003, 265-270.