Historical/Less Common Bariatric Procedures
The field of bariatric surgery dates all the way back to the 1950s with the advent of the intestinal bypass. Since that time, many different sorts of procedures to affect weight loss have been devised. In fact, over 30 procedures have been evaluated for weight loss with most of these falling by the wayside for a variety of reasons. The following is an outline of some of these procedures. This information is provided such that the reader can be well educated as to the spectrum of options available.
Jejunoileal Bypass (JIB)
The JIB was the first procedure developed specifically for weight loss. It became available in the 1950s and was very common until the mid to late 1970s. This was purely a malabsorptive procedure which involved dividing the intestine and reconnecting it to itself way downstream, almost where it enters the colon. This created a truly bypassed segment which was completely outside the flow of intestinal contents, thus drastically decreasing the absorptive surface of the intestine.
Popularity grew because it was easily performed, created large amounts of weight loss, and required minimal effort from the patients. Unfortunately, the anatomy created with this caused severe complications such as protein malnutrition, as well as severe electrolyte abnormalities, arthritis, kidney disease, and even liver failure. Furthermore, the intestine eventually accommodated to this shorter length and the vast majority of patients gained their weight back.
The JIB has not been performed for many years and in fact, it is recommended by many that those who have undergone this procedure should have it reversed.
Vertical Banded Gastroplasty (VBG) and Horizontal Gastroplasty (HG)
These two procedures were devised in the late 1960s and early 1970s in an effort to develop an operation that would be as effective as the Jejunoileal bypass and newly developed gastric bypass, but without the potential complications. Commonly referred to as the “stomach stapling”, both involved partitioning the stomach with a stapling device in order to drastically reduce its size and create restriction.
The HG was first tried in response to the problems with the JIB and involved longitudinal division of the top half of the stomach. This procedure quickly became popular despite essentially no clinical data to support its efficacy, and soon it was found to be a complete failure. This is mostly because the top portion of the stomach easily expands and stretches, creating a large reservoir for food.
Soon after developing the gastric bypass, one of its originators developed the vertical gastroplasty. This procedure was a little more complex, creating a small, vertical pouch along the thick non-expandable portion of the stomach. The outflow of this pouch was controlled by an elastic ring or band of mesh. This is similar to the anatomy created with the adjustable band of today. This was one of the most frequently performed operations for morbid obesity, and many were performed between the 1970s and early 1990s. However, long-term studies have shown that weight loss is not maintained and that there is a high rate of revisional surgery. This procedure has been abandoned and does not have a role in current surgical practice.
Biliopancreatic Diversion with Duodenal Switch (BPD-DS)
The original version of this surgery (without the duodenal switch) was developed in Italy in the 1970s. This is a relatively complex operation involving both gastric restriction and rearrangement of the bowel.
The primary mode of weight loss is by way of malabsorption as most of the bowel is bypassed (but in a different manner than with the JIB, thus avoiding many of the severe complications). This procedure was modified in the United States in the mid-1980s to the BPD-DS.
Since 2001, some centers are now performing this procedure laparoscopically. These operations may be more effective in achieving long-term weight loss and, in fact, have been shown to have the highest success rate of any operation ever developed. However, this is at a cost of a high rate of malnutrition not seen with other procedures. For this reason, most bariatric surgeons defer recommending this procedure as a first line operation for weight loss. However, there are several centers throughout the country that do offer the BPD-DS.
“Long Limb” Gastric Bypass
Some surgeons have worked to capitalize on the weight loss experience with the BPD-DS (above) without creating malnutrition. One strategy has been simply to create a much longer bypass limb during the standard gastric bypass. This is done by making the small bowel connection much further downstream (Roux limb is longer) so that food and digestive juices mix for a shorter distance.
There is some controversy as to what truly constitutes a “long limb”, but most agree that it is necessary to measure backwards from the end of the small bowel to calculate precisely how long this “common channel” is. The reason for this is because there is a significant variation in the total length of the intestine between individuals.
The Long Limb Gastric Bypass is reported to have more weight loss than the standard gastric bypass within the first two years of surgery. However, most studies show that long-term weight loss is not greater than with a standard gastric bypass and further, there is demonstrated a higher rate of electrolyte disturbances and other nutritional complications. Despite this, some continue to advocate this procedure and it may have a role in the “super obese” (BMI greater than 60).
Experimental evidence shows that when a low-level shock is applied to the correct location on the stomach, then the nerves which stimulate hunger pains will be suppressed. This concept has been carried over to postulate the placement of a gastric pacer to the stomach in order to suppress hunger. This is not unlike a cardiac pacer, and leads are placed directly in the stomach wall via laparoscopic technique. As with many previous ideas, this is not carried over to demonstrate significant weight loss in clinical studies. Given this preliminary data, most hold that the gastric pacing will have minimal, if any role in surgical weight loss.
This involves placement of a balloon into the stomach by endoscopic means. This balloon is then inflated and therefore takes up space in the stomach, decreasing its capacity. As a result, one feels fuller with smaller amount of food. This technique has been studied since the late 1980s.
Weight loss has been shown to be moderate at best, and the balloon needs to be removed after six months. Further, it causes a significant amount of side effects, mostly related to nausea, vomiting, and intermittent gastric obstruction. As with any bariatric procedure, when reversed, the vast majority will gain their weight back.
A 2007 review of the available studies concluded that the intragastric balloon did not produce convincing evidence of greater weight loss than conventional non-surgical treatment. Likewise, it has failed to get much attraction from bariatric surgeons. This device has not been approved by the FDA and is considered investigational at the current time.
This procedure has been designed to mimic the gastric sleeve, but in such a way as to eliminate the need for a staple line (and possible complications) while creating a potentially reversible procedure. It involves the folding (or plicating) of the stomach upon itself repeatedly with rows of suture. This creates a final product that looks similar to a gastric sleeve, but without the need to remove the remaining portion of the stomach.
Gastric Plication has actually been performed for several years outside of the U.S. with results similar to Sleeve Gastrectomy, however with only up to three years follow up. Several centers are currently performing studies on the safety and efficacy of this procedure. In October 2011, the American Society of Bariatric and Metabolic Surgery issued a statement indicating that this procedure may prove to be a viable option for weight loss, however it was emphasized that the available data is insufficient to draw any conclusions concerning its safety and efficacy. Further, the procedure should be considered investigational and only performed under a research protocol.
It is not approved by the FDA and by major health insurance carriers. A variation of this technique is also currently under study involving placement of a laparoscopic band at the top portion of a plicated stomach. This has been termed the “Banded Plication”. There are currently only two reports of this variation in the available literature, but preliminary data appear promising. As with the Gastric Plication itself, the Banded Plication is considered investigational at the current time.