These early surgeries gave bariatric surgery a bad name. Some of the prejudice against weight loss surgery can be traced to these procedures that either failed early on, or had significant morbidity and mortality (our surgical term for complications and death) for their patients.
Some insurance companies deny patients payment for either a long-limb gastric bypass or the duodenal switch, thinking that the malabsorptive part of the procedure is reminiscent of the jejunal-ileal bypass. There is a great deal of prejudice against weight loss surgery among physicians. Often patients come to my office after begging their primary care physician to refer them for a consultation for bariatric surgery.
Surgical history is filled with stories about unsuccessful, at the least, or deadly early attempts at the first weight loss surgery. Cardiac surgery is an example: today coronary artery bypass is almost a “routine procedure,” but in the early days of cardiac operations, there were many failures.
Stomach operations were the same. Many of the first stomach operations led to death, and all weight loss surgeons know the name of the first man who successfully operated on the stomach (Bilroth—a Swedish surgeon who worked in Vienna, and did this operation in 1881).
The National Institutes of Health and Weight Loss Surgery
Bariatric surgery continued to evolve and many careful and thoughtful weight loss surgeonscontinued to develop surgeries and watch their results. The most famous was a weight loss surgeon from Iowa, Dr. Mason, who not only developed and perfected a couple of operations, but also followed patients and encouraged other surgeons to follow their patients to see the long-term effect of surgery for weight loss.
But obesity and weight loss surgery, were also watched by a group of scientists and physicians who were brought together by the National Institute of Health to form “consensus” statements. These are “non-advocates,” meaning that the members of this panel were not advocating any particular procedure, merely gathering the research and facts at that time, to make a determination about obesity surgery. There was a 1978 consensus statement that showed concern for the jejunal-ileal bypass, which was ultimately abandoned.
National Institute of Health bariatric surgery consensus statement
The major consensus statement was released in 1991. Among their findings, the panel recommended that:
- Patients seeking therapy for severe obesity for the first time should be considered for treatment in a non-surgical program with integrated components of a dietary regimen, appropriate exercise, and behavioral modification and support.
- Restrictive or gastric bypass procedures could be considered for well-informed and motivated patients with acceptable operative risks.
- Patients who are candidates for weight loss surgical procedures should be selected carefully after evaluation by a multidisciplinary team with medical, surgical, psychiatric, and nutritional expertise.
- The operation be performed by a weight loss surgeon substantially experienced with the appropriate procedures and working in a clinical setting with adequate support for all aspects of management and assessment, and
- Lifelong medical surveillance after surgical therapy is a necessity.
It is also useful to quote them
Patients whose BMI exceeds 40 are potential candidates for weight loss surgery if they strongly desire substantial weight loss, because obesity severely impairs the quality of their lives. They must clearly and realistically understand how their lives may change after operation.
In certain instances less severely obese patients (with BMI’s between 35 and 40) also may be considered for weight loss surgery. Included in this category are patients with high-risk co-morbid conditions such as life-threatening cardiopulmonary problems (e.g., severe sleep apnea, Pickwickian syndrome, and obesity-related cardiomyopathy) or severe diabetes mellitus. Other possible indications for patients with BMI’s between 35 and 40 include obesity-induced physical problems interfering with lifestyle (e.g., joint disease treatable but for the obesity, or body size problems precluding or severely interfering with employment, family function, and ambulation).
Back to weight loss surgery—What were they doing?
Soon the jejunal-ileal bypass procedure was gone and various weight loss surgeons were working on their own version of bariatric surgery. The majority of those efforts are seen in the drawing.
I will go over the various surgical options available today. Some are simple variations of another and will not have much to say about them. Suffice it to say: Weight loss surgery is a well-studied option for obesity. Bariatric surgery continues to evolve. Newer surgeries such as the lap-band (introduced to this country in 2001 and to Europe in 1993) and duodenal switch (used since 1988 in this country) are two of the latest versions. The widespread use of laparoscopy to perform bariatric surgery has decreased the hospital stay and improved laparoscopic skills among many of the weight loss surgeons in this country. No doubt, in the future, as the biology of obesity is better understood, we will develop other procedures perhaps in conjunction with better medication, for weight loss.
The future of Weight Loss Surgery
Pacemakers and balloons
There are two new tools on the horizon for weight loss surgery. One is the Gastric pacemaker where, during the procedure, some electrodes are placed on your stomach and a battery is implanted under your skin. This device works, so they say, by decreasing your appetite. It is not yet approved by the FDA and is currently in trial in the United States. The idea is appealing, but the results are not as good as another minimally invasive weight loss surgery—the lap-band. Both require the same sort of operation, but the pouch for the battery is larger than the pouch for the lap-band port. Electrodes have to be periodically replaced at a far higher rate than the tube for the lap-band. Weight loss for the pacemaker has yet to equal the lap-band, but the results are for early trials.
Remember the balloons placed in the stomachs in the 1980’s? They had a few problems, like sometimes they would deflate and cause a bowel obstruction, so they are no longer used. The idea was a good one, however. A balloon in the stomach made you feel full so you ate less. Well, building on that idea, a new device is being developed and a new trial will be underway. The idea behind this balloon-like device is to use it as a temporary measure for people who have a lot of weight to lose, such as those in the super-morbid obese class. By losing some weight prior to surgery, it will allow them to have a safer operation. If you can bring a patient from a BMI of 60 down to 45, the risk of weight loss surgery decreases substantially. Could this be used for the last 40 pounds or so? Maybe, but that is not the intent.
A number of adjustable Lap-bands are used in Europe and the rest of the world. The only approved Lap-band in the United States is the lap-band manufactured by Inamed (acquired by Allergan and more recently acquired by Apollo Endosurgery Inc. of Austin, Texas). Other bands will be arriving once they have undergone FDA trials. For example, Johnson and Johnson brought their REALIZE Lap-band to market in 2007.