Obesity is a disease. We have all seen the Metropolitan Life Insurance Company standards that have the “ideal” body weight. These were initially determined in a height/weight category by simply noting that there was an increased death rate among people who had certain height/weight ratios. But, society, as well as industry and most of the medical profession, did not consider obesity to be a disease.
Weight loss surgeon, J. Howard Payne first coined the term “morbid obesity” in an attempt to convince insurance companies there was a level at which obesity became a disease, and that there were some surgical treatments for that disease. Those surgical treatments were based upon years of clinical observation and trials.
The field of weight loss surgery is called “bariatric surgery,” which always sounds like we are diving—and sometimes we think we are.
History of Weight Loss Surgery
(Or gee, you don’t need this but here it is anyway)
Weight loss surgeons are keen observers of their patients. We have fat ones, skinny ones, all kinds. But when someone who once was fat becomes skinny, we pay attention to what we did.
So it all started with an observation—that patients who have less small bowel get skinny. The small bowel (three sections that are the duodenum, jejunum, and ileum) is the major “absorptive” part of the intestine. Some patients, for a variety of reasons, loose a portion of their small bowel. Ok, they don’t lose it; some very nice weight loss surgeon has to remove the small bowel. If a lot of small bowel is removed (more than 80 percent) the patients are given the diagnosis of “short bowel syndrome.” Weight loss surgery patients with short bowel syndrome are a challenge, and before the days when we could give them nutrition through an intravenous line, many of these patients died of malnutrition. The idea then was that if you bypassed a lot of the small bowel on purpose, the patients would lose pounds.
The most common and popular weight loss surgery in the 1960’s and 1970’s was the jejunal ileal bypass. Essentially, you bypassed all but a foot and a half of the nine feet of small bowel. Many of these weight loss surgery patients found they could eat anything they wanted and still lose pounds. It was primarily a malabsorptive procedure that led to rapid weight loss, often one hundred pounds in the first couple of months. Over the long term, however, some patients developed severe complications. Because of these complications, any individual who had this operation is advised to have the procedure reversed or revised into another bariatric surgery. Liver failure, which led to the death in 91 weight loss surgery patients, was the most severe problem, and accounted for the main reason this procedure is no longer offered. Other complications attributed to this weight loss surgery include kidney stones, arthritis, and osteoporosis from disturbances in calcium metabolism. The operation essentially hooked the first part of the small bowel to the colon. This decreased the amount of absorption that patients could have and, in the process, it increased diarrhea and made for some severe disturbances in the electrolytes of these patients.
One famous bariatric surgeon spent the first half of his career doing these surgeries and the second half of his career undoing them. Then there was the other problem. After a while, the remaining 18 inches of small bowel accommodated and patients began to regain pounds. This procedure hasn’t been done in the United States since the 1980’s, although there are still a number of people around who had the operation. About once a year, most weight loss surgeons see one who wants a revision to some other procedure. So, if you or a friend of yours had the “jejunal-ileal” bypass, we recommend you see your local bariatric surgeon to have that procedure revised.
The next observation came from those surgeons who did a lot of stomach operations. They noticed that if they removed part of their patient’s stomach, the patient could not eat as much and they tended to lose pounds. This was a forced “portion control.” This began a series of operations whose purpose was to limit how much a person could eat or drink. These are called “restrictive” surgeries. Pure gastric restrictive surgeries were first started with true “stomach stapling.” A staple gun was fired across the stomach, with a small opening in the middle, allowing for a little food to pass through. This operation failed because the upper stomach was able to distend easily. One of my favorite hospitals in Phoenix Arizona was a pioneer in this stomach stapling procedure, doing 12,000 of them over time. This operation was ultimately replaced with the vertical banded Gastroplasty (VBG), which is a much better procedure.
These weight loss surgeries, and variations of them, are mentioned because both can easily be revised to another type of bariatric surgery. Revision of these procedures is offered to patients who have had either of these surgeries.