Weight-reduction surgery—past and present

Doris Rapp, PharmD, PA-C; John J. Gleysteen, MD

Dr. Rapp is Associate Professor and Program Director, University of Alabama at Birmingham Surgical Physician Assistant Program. Dr. Gleysteen is Professor of Surgery and Surgical Service Chief, Veteran's Administration Medical Center, Birmingham, and Medical Director, University of Alabama at Birmingham Surgical Physician Assistant Program. The authors have indicated no relationships to disclose relating to the content of this article.

If these procedures are to produce weight loss and improved health, thorough evaluation and careful, effective counseling and education are essential.

Surgical intervention can be a safe and effective approach to promoting and maintaining weight loss for severely obese patients after medical and behavior therapies have failed. The surgical approach does, however, carry the risk of serious complications, including death (see "Weighing the risks of a bariatric procedure"). There is no single indication for surgical referral; whether the patient is an appropriate candidate is determined by both the degree of obesity and the comorbidities associated with or aggravated by it.^1,2 Some of these comorbidites are themselves life-threatening conditions, including coronary heart disease, diabetes, and hypertension, while others, such as obstructive sleep apnea, affect the patient's quality of life^1-4 (see Table 1).

 

TABLE 1 The complications of morbid obesity

Accelerated atherosclerosis Amenorrhea and infertility Angina pectoris Arthritis in weight-bearing joints, immobility Cancer Depression, social isolation Gallstones Gastroesophageal reflux disease Hernias Hyperlipidemia Hypertension Rash, skinfold infection Sleep apnea Sudden death Type 2 diabetes Urinary stress incontinence Venous stasis, leg ulcers, deep venous thrombosis

Patients who are considering weight-loss surgery should understand that the goal of this procedure is to allow them to make healthy lifestyle changes; the patient must be committed to following a diet and exercise regimen after surgery and should have realistic weight-loss expectations (see "How to know if the patient is ready for bariatric surgery"). Furthermore, patients should understand that their age, weight before surgery, overall health status, motivation and commitment, ability to exercise, and the surgical procedure used can all affect the amount of weight lost. For example, a patient in relatively good health who has some ability to exercise is likely to lose more weight than a patient of the same height, weight, and age who is in poor health and has a low tolerance for exercise.

 

How to know if the patient is ready for bariatric surgery Growing evidence suggests a higher prevalence of psychiatric problems among patients who seek medical or surgical treatment for obesity than in the general population.1,2 In addition to the likelihood that these problems contribute to obesity and overweight, any psychiatric comorbidity may impede the patient's adjustment to life after bariatric surgery and so must be identified and managed before the patient undergoes the procedure. Comorbid psychiatric conditions that have been associated with obesity include depression, phobias, posttraumatic stress disorder (PTSD), bulimia nervosa, personality disorders,3 bipolar disorder,4 binge eating disorder (BED),5 and obsessive-compulsive disorder.6 Patients who seek bariatric surgery often report depression, and many also have an anxiety disorder. The psychological impact of undergoing a bariatric procedure has not yet been determined, and although one study suggests that psychopathology may recede following bariatric surgery,1 it should not be assumed that psychological improvement is a result of undergoing the procedure. No studies have examined the long-term psychological impact of bariatric surgery. Psychological and psychosocial concerns must be addressed when evaluating a patient who seeks bariatric surgery. For example, someone whose obsessive-compulsive focus on food caused obesity may later exercise compulsively after bariatric surgery. Sexual trauma leading to PTSD has also been associated with obesity; many women have reported gaining weight to protect themselves from further sexual violation by creating a "fat barrier" between them and anyone who might be interested in them sexually. BED, a disorder characterized by eating far more food within 2 hours than is normal under ordinary circumstances,7 is also associated with obesity.6 Nearly all patients with BED also have depression. Many patients who underwent bariatric surgery 20 years earlier have regained the weight because of continued, if modified, binge behavior—despite a reduced stomach capacity. The prevalence of psychiatric comorbidity among obese patients warrants a psychosocial assessment as part of the evaluation for every patient seeking bariatric surgery. This assessment should be performed by a mental health professional who is trained to work with obese patients.8 The clinician should include a psychosocial history and seek to identify the cause of the patient's obesity as well as any behavioral contraindications to treatment, determine the goals of therapy after surgery, and prepare the patient for treatment. The presence of psychological comorbidity may be revealed during a workup that includes a psychiatric history and mental status evaluation; lifestyle assessment; history of weight, weight loss, and treatment; assessment of eating patterns, disorders, and eating-related attitudes and beliefs; physical activity assessment; a social history; and an assessment of the patient's perceived obstacles to weight loss and readiness to change. Follow-up psychological testing is warranted if the subjective evaluation suggests that the patient may have either a personality or eating disorder or depression. Such problems may herald an impediment to a healthy approach to weight loss after surgery and should be addressed with treatment. —Katherine T. Kelly, PhD, MSPH 1. Maddi SR, Fox SR, Khoshaba DM, et al. Reduction in psychopathology following bariatric surgery for morbid obesity. Obesity Surg. 2001;11:680-685. 2. O'Neil PH, Jarrell MP. Psychological aspects of obesity and dieting. In: Wadden TA, Van Itallie TB, eds. Treatment of the Seriously Obese Patient. New York, NY: Guilford Pr; 1992:252-272. 3. Black DW, Goldstein RB, Mason EE. Prevalence of mental disorders in 88 morbidly obese bariatric clinic patients. Am J Psychiatry. 1992;149:227-234. 4. Fagiolini A, Kupfer DJ, Houck PR, et al. Obesity as a correlate of outcome in patients with bipolar I disorder. Am J Psychiatry. 2003;160:112-117. 5. Matos MI, Aranha LS, Faria AN, et al. Binge eating disorder, anxiety, depression and body image in grade III obesity patients. Rev Bras Psiquiatr. October 2002:24:165-169. 6. Fontenelle LF, Mendlowicz MV, de Menezes GB, et al. Comparison of symptom profiles of obese binge eaters, obese non-binge eaters and patients with obsessive compulsive disorder. J Nerv Mental Dis. 2002;190:643-646. 7. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). Washington, DC: American Psychiatric Assoc; 2000. 8. Andrews G, LeMont D, Myers S, et al. Caring for the Surgical Weight Loss Patient. Sierra Madre, Calif: Wheat Field Publications; 2003.

The primary indication for surgical intervention that health insurance carriers recognize is the patient's body mass index (BMI), which can be calculated by dividing weight in kilograms by height in meters squared, multiplied by 703. A BMI of 40 kg/m² or greater—or a BMI of 35 to 39.9 kg/m² with serious comorbidities such as diabetes or hypertension, or a failure to sustain weight loss using behavior changes, exercise, and drug therapy—is an indication for surgical intervention.^1,3 Secondary indications in a patient who has a BMI of 35 to 39.9 kg/m² include an inability to perform activities of daily living or a significant impairment in quality of life, together with low surgical risk and sufficient motivation to make lifelong dietary changes after surgery.³

How bariatric surgery works

The various bariatric procedures are not cosmetic and do not remove fat. A bariatric procedure may have a restrictive effect, a malabsorptive effect, or both.^1-3,5,6 A restrictive procedure (for example, vertical banded gastroplasty [VBG]) reduces the size of the stomach, limiting the amount of food that can be digested at one time. No part of the intestine is bypassed in restrictive procedures. A malabsorptive procedure (such as jejunoileal bypass) diverts food away from a large part of the intestines, preventing some degree of nutrient absorption. The most commonly performed procedure today, the Roux-en-Y gastric bypass (RYGB), is a combination procedure; the stomach is reduced and a portion of the small intestine is bypassed, although not to the extent of a purely malabsorptive procedure. With a procedure such as the RYGB, patients are restricted in their consumption and also enjoy the benefit of limited (particularly fatty) malabsorption.

Specific procedures

Various procedures that have been used over the years are shown in Table 2, which also provides a snapshot of the common postsurgical complications that were associated with the procedures performed during the evolution of bariatric surgery. Surgical treatment for morbid obesity began in the mid-1950s with the jejunocolic bypass.^1,7 This surgery was associated with persistent, severe fluid and electrolyte abnormalities as well as with liver dysfunction and failure. It was replaced in the 1960s and early 1970s by the jejunoileal bypass (JIB),⁸ in which an anastomosis of the proximal jejunum to the distal ileum provides an intact ileocecal valve. Fluid and electrolyte imbalances still occurred with JIB, however, along with other complications such as oxalate renal stones, migratory polyarthralgias, abdominal bloating, and liver dysfunction.³ Many patients who had this procedure more than 30 years ago have an intact JIB today. This procedure is still performed, but usually for temporary weight loss in a surgically risky patient, before a later conversion to a gastric bypass.⁹

 

TABLE 2 Bariatric procedures over time
Procedure	Introduced	Complications
Jejunocolic bypass	Mid 1950s	Fluid and electrolyte abnormalities, liver failure
Jejunoileal bypass	1960s– early 1970s	Repeated diarrhea, liver failure, electrolyte imbalances, renal stones, hypoalbuminemia, abdominal bloating, long-term mortality of 8%-10%
Jejunal loop gastric bypass of Mason	Late 1960s	Anastomotic leaks, reflux, more weight regain than in JIB
Roux-en-Y gastric bypass	Late 1960s	Staple-line disruption and marginal ulcer formation, significant dumping syndrome, iron or vitamin B12 deficiency anemias, possible Roux limb obstruction or Gl stenosis
BPD and BPDDS	Late 1970s	Deficiencies in vitamins A, D, E, and K, protein malnutrition, liver abnormalities, possible bone disease secondary to calcium malabsorption, iron deficiency anemia, malodorous stool and flatus
Gastroplasty	Mid 1970s	Staple-line dehiscence, ring or band erosion, gastroesophageal reflux
Gastric balloon	1980s	Minimal weight loss, balloon breakage and migration with intestinal obstruction
Gastric banding	1970s	Slippage or migration of the band, development of a large upper gastric pouch and reflux and vomiting
Adjustable gastric banding	Late 1980s	Access port leakage, band erosion or slippage
Key: BPD, biliopancreatic diversion; BPDDS, biliopancreatic diversion with duodenal switch; JIB, jejunoileal bypass.

Biliopancreatic diversion with duodenal switch The malabsorptive procedures performed today are the biliopancreatic diversion (BPD) developed in the late 1970s and the BPD with duodenal switch (BPDDS) developed a few years later.^1,10-13 In the BPD, a three-quarters gastrectomy is performed and a distal segment of the small intestine is connected to the stomach remnant, completely bypassing the duodenum and the jejunum. The bypassed biliopancreatic limb of small bowel is then attached to the side of the distal limb about 50 to 100 cm before the ileocecal valve.¹⁰ Major digestion occurs in this short common channel.¹¹ A cholecystectomy is also performed to prevent gallstones from forming as a result of bile stasis and rapid weight loss.¹⁰ Although reduced stomach capacity is responsible for the initial weight loss, the interruption in the digestive process sustains the loss.¹⁰

Among the bariatric procedures, BPD results in greater weight loss. It requires greater surgical expertise, however, and close long-term follow-up is needed—initially every 3 months, and then annually—to monitor for possible nutritional deficiencies.³ A CBC should be obtained to detect anemia (hemoglobin, hematocrit), and vitamin B₁₂, folate, and iron levels should be checked. Serum calcium values should also be monitored due to the potential for osteoporosis. The most serious potential complication is protein malnutrition, which is associated with hypoalbuminemia, anemia, edema, alopecia, and other symptoms. An advantage of BPD is that the patient can eat more than with other restrictive procedures and still lose weight.

In the alternative BPDDS procedure, an intact pylorus and duodenal segment appear to avoid the postoperative dumping, diarrhea, and stomal ulceration that were complications of BPD.^3,10-12 In the BPDDS, the greater curvature of the stomach is resected, leaving a lesser curvature sleeve of stomach (120-cc capacity) that extends beyond the pyloric valve and retains a small segment of the duodenum (see Figure 1). The remainder of the small bowel anatomic rearrangement is similar to that for BPD, although compared to BPD, this procedure allows for greater nutrient absorption.

Click here to view full-size graphic

Roux-en-Y gastric bypass Developed in the late 1960s, the RYGB is another procedure that results in both restriction and malabsorption (see Figure 1). The procedure is the most commonly performed bariatric surgery in the United States and is considered the gold standard because of its success and the existence of many years of follow-up studies.¹⁰ In this procedure, the stomach is vertically partitioned with staples or divided so that only a small pouch (approximately 15-20 cc) remains functional at the esophagogastric junction. The Roux limb (proximal jejunal segment) is attached to the stomach pouch, bypassing the remainder of the stomach, duodenum, and short section of jejunum. Because the Roux limb cannot process dense calories such as those from sugar or fat, they are dumped from the stomach pouch into this bowel segment, producing the so-called dumping syndrome.¹⁰ This symptom complex—originally anticipated as a mechanism to reduce caloric intake after an RYGB—does not occur in all patients who have had this procedure.

Patients who have an RYGB are at risk for certain vitamin and mineral deficiencies—particularly deficiencies of vitamin B₁₂ and iron—a problem which can be overcome with a healthful diet plus daily vitamin and mineral supplementation (see "Weighing the risks of a bariatric procedure"). In addition, patients who have a gallbladder without stones at the time of surgery may be given preventive oral dissolution therapy during the first 6 postoperative months, when risk of gallstones is greatest. Although gallstone prevention protocols exist, they are not universally followed.

Vertical banded gastroplasty In the mid 1970s, gastroplasty, or stomach stapling, was introduced to simplify gastric restriction.³ Successful approaches to this type of surgery are VBG and silastic ring gastroplasty (SRG). In both procedures, the stomach is partitioned vertically along the lesser curvature, with the gastric outlet reinforced with either a prosthetic band or silastic ring to prevent postsurgical enlargement of the stoma.^3,14,15 Patients who have a gastroplasty usually lose less weight than patients who have an RYGB, but they may be more satisfied overall. Patients learn to either take small bites and chew food to a soft consistency before swallowing or risk discomfort, reflux, or regurgitation from a temporary blockage of the stomach outlet. Some patients circumvent this forced behavioral change by consuming calorie-dense foods high in sugar and fat, such as milkshakes and ice cream, which pass directly through the gastric outlet. Pouch enlargement and dehiscence of the vertical staple line are complications of repeated bouts of vomiting by patients who consistently overeat.¹⁰

In the 1980s, surgeons tried using intragastric balloons that, once inserted into the stomach, were inflated to occupy gastric space, creating satiety. Weight loss was minimal and erratic, but the greater problem was balloon rupture and subsequent migration through the intestines, occasionally causing obstruction.^3,16 Although the balloon approach resurfaces periodically with technical modifications, the success rate has not changed.³

Gastric banding and adjustable gastric banding Introduced in the 1970s, these procedures involve wrapping a band around the stomach to achieve a nearly complete partition of the upper stomach (see Figure 1). The band creates a small opening from the upper pouch to the lower stomach, which controls the rate of emptying. The results of gastric banding were similar to those of gastroplasty; the upper gastric pouch enlarges to accommodate extra food. In some cases, the outlet was too large and the patient did not lose weight.³ The basic gastric banding concept was updated in the 1980s with adjustable gastric banding (AGB) and again in the 1990s with a laparoscopically placed stomach band (lap band).^17,18 Both these techniques allow the surgeon to regulate the band tension via saline insertion into a balloon that lines the interior of a flexible band through an access port placed under the skin. This adjustable approach has proven to be more successful because it allows the patient to gradually get used to changes in the quantity of food consumed. Significant problems seen with the band procedures are band erosion, breakage, or slippage and difficulty swallowing.⁷ The slower rate of weight loss, however, is regarded as a clinically significant advantage.

The laparoscopic approach

All bariatric operations can be performed laparoscopically by experienced surgeons.³ Laparoscopy is usually more expensive than an open approach because of initially increased operating time and disposable instrument costs, but it generally causes the patient less postoperative pain and results in shorter hospital stays, faster return to work, and avoidance of most incisional hernias.¹⁰ It is also associated with less stress response to surgery and may reduce the occurrence and severity of related complications. In addition, patients undergoing a laparoscopic procedure have better postoperative pulmonary function than those undergoing an open procedure.

Although laparoscopic bariatric surgery is an increasingly common surgical approach, it does have drawbacks. Equipment malfunction, inadequate exposure of GI contents, injury to a vital organ or structure, or an anastomotic leak usually requires conversion to an open procedure. Many of the perioperative complications are attributable to surgeon experience.

Conclusion

Since it was first introduced in the 1950s bariatric surgery has been the answer for many morbidly obese patients who could not lose weight with conventional dieting. Different procedures have evolved over the years, ranging from those that are purely restrictive to those that are purely malabsorptive and to a combination of the two. Weight loss is usually more successful with the RYGB than with purely restrictive procedures. For many patients, comorbid conditions associated with obesity improve or resolve after weight-loss surgery, although these procedures can introduce other complications. Patients who choose the surgical option should not do so without adequate research, counseling, and family support. Although all bariatric surgical procedures require the patient's commitment to modify eating and exercise habits, bariatric surgery provides a reliable tool in carefully selected and motivated patients to help them toward a lifetime of controlled eating and exercise.

 

KEY POINTS in this article Although it can be life saving, the surgical approach to weight loss carries the risk of serious complications, including death. Patient age, weight before surgery, overall health status, motivation and commitment, ability to exercise, and the surgical procedure used can all affect the amount of weight lost. The Roux-en-Y gastric bypass is currently the most commonly performed bariatric surgery in the United States.

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Doris Rapp. Weight reduction surgery--past and present. JAAPA April 2004;17:35-41.

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