Obesity Surgery History

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 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.” 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 weight.

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 patients found they could eat anything they wanted and still lose weight. 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 surgery is advised to have the surgery reversed or revised into another weight loss surgery. Liver failure, which led to the death in 91 patients, was the most severe problem, and accounted for the main reason this surgery is no longer offered. Other complications attributed to this surgery include kidney stones, arthritis, and osteoporosis from disturbances in calcium metabolism. The surgery 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 their weight. This surgery hasn’t been done in the United States since the 1980’s, although there are still a number of people around who had the surgery. About once a year, most surgeons see one who wants a revision to some other form of surgery. So, if you or a friend of yours had the “jejunal-ileal” bypass, we recommend you see your local bariatric surgeon to have that surgery revised.

The next observation came from those surgeons who did a lot of stomach surgery. They noticed that if they removed part of their patient’s stomach, the patient could not eat as much and they tended to lose weight. 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 was a pioneer in this stomach stapling procedure, doing 12,000 of them over time. This surgery was ultimately replaced with the vertical banded Gastroplasty (VBG), which is a much better surgery.

These weight loss surgeries, and variations of them, are mentioned because both can easily be revised to another type of weight loss surgery. Revision of surgery is offered to patients who have had either of these surgeries.

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