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The evolution of minimally invasive bariatric surgery
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Available online at www.sciencedirect.com
journal homepage: www.JournalofSurgicalResearch.com
The evolution of minimally invasive bariatric surgery Andrew J. Batchelder, MRCS,a,b Robert Williams, FRCS DM,a,b Christopher Sutton, FRCS, MD,a,b and Achal Khanna, MRCSEd, MPhila,b,* a b
Department of General Surgery, Leicester Royal Infirmary, Leicester, UK Department of Oesophago-gastric Surgery, Leicester Royal Infirmary, Leicester, UK
article info
abstract
Article history:
Background: Obesity is a pandemic associated with significant morbidity and mortality. This
Received 17 December 2012
historical article charts the progress of successful strategies that have been used to tackle
Received in revised form
weight loss from dietary modifications to the development of surgical interventions that
3 February 2013
have subsequently evolved. It also provides a pre´cis of the reported outcome data following
Accepted 19 February 2013
minimally invasive bariatric procedures.
Available online 14 March 2013
Methods: A literature review was performed. All articles relevant to the progression of bariatric surgery and minimally invasive surgery were assessed, as were those articles that
Keywords:
described the ultimate evolution, combination, and establishment of the two techniques.
Evolution
Results: This article charts the progression of early weight loss strategies, from early dietary
Minimally invasive
modifications and pharmacologic interventions to initial techniques in small bowel bypass
Bariatric surgery
procedures, banding techniques, and sleeve gastrectomies. It also describes the simultaneous developments of endoscopic interventions and laparoscopic procedures. Conclusions: A range of procedures are described, which differ in their success in terms of loss of excess weight and in their complication rates. Weight loss is greatest for biliopancreatic diversion followed by gastric bypass and sleeve gastrectomy and least for adjustable gastric banding. Bariatric surgery is an evolving field, which will continue to expand given current epidemiologic trends. Developments in instrumentation and surgical techniques, including single access and natural orifice approaches, may offer further benefit in terms of patient acceptability. ª 2013 Elsevier Inc. All rights reserved.
1.
Introduction
Obesity is a pandemic associated with significant morbidity and mortality. Globally, a body mass index (BMI) 25 kg/m2 is the fifth leading risk factor for mortality and accounts for 44% of the burden of diabetes, 23% of the burden of ischemic heart disease, and between 7% and 41% of certain cancer burdens [1]. Data from the World Health Organization survey in 2010 estimate that 67.8% of males and 63.8% of females over the age
of 15 y in the UK have a BMI 25 kg/m2 [2]. The extent of the problem is increasing with 31% of boys and 28% of girls aged 2e15 y in England classed as overweight or obese [3]. This historical article charts the progress of strategies that have been used to tackle weight loss from dietary modifications to the development of surgical interventions that have subsequently evolved. It also provides a pre´cis of the reported outcome data following minimally invasive bariatric procedures.
* Corresponding author. Department of Surgery, Level 6 Balmoral Building, Leicester Royal Infirmary, Leicester, LE1 5WW, UK. Tel.: þ44 116 258 5247; fax: þ44 116 258 6083. E-mail address: [email protected] (A. Khanna). 0022-4804/$ e see front matter ª 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2013.02.036
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2.
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Methods
A literature review was performed. All articles relevant to the progression of bariatric surgery and minimally invasive surgery were assessed, as were those articles that described the ultimate evolution, combination, and establishment of the two techniques.
however, in 1963, the first negative results of jejunoileal bypass were reported [15]. It became apparent that small intestinal bypass was a cause of significant morbidity and mortality, with patients developing features of both short bowel and blind loop syndromes [16,17]. Such complications included bloating, arthralgia, and electrolyte imbalance due to profuse diarrhea, deficiency of fat-soluble vitamins and other micronutrients, cholelithiasis, renal calculi, and liver failure.
3.2.
3.
Dietary modification is a successful strategy for weight loss, which has been recognized for several centuries. In 1863, Banting [4], an obese English undertaker and distant relative of Frederick Banting who co-discovered insulin, reported a weight loss of 23.5 kg through adherence to a diet low in refined carbohydrates. Although not the first to highlight the benefits of such a diet, the principle contribution of Banting was to popularize the concept. Subsequently, Atwater et al. [5] invented the respiration calorimeter in 1896, enabling the measurement of energy yielded by certain foodstuffs and the notion of calorific values was conceived. The 20th century has seen the proposal of a plethora of dietary modifications for weight loss with varying degrees of success. Current guidelines recommend the consumption of a balanced diet, as described by Banting, in conjunction with regular physical activity and, where appropriate, behavioral interventions [6]. The advent of pharmacologic interventions for obesity has, however, been associated with a number of catastrophes. As early as 1893, ovine thyroid extract was trailed for weight loss with inevitable catabolic consequences [7]. In the 1930s, dinitrophenol was noted to greatly increase metabolic rate by uncoupling oxidative phosphorylation [8]. However, it was subsequently linked with the development of peripheral neuropathy and cataracts [9]. A string of other agents followed, including amphetamine, aminoxaphen, fenfluramine, and phentermine. All were linked with significant toxicities. Most recently, sibutramine was withdrawn due to increased risk of myocardial infarction and stroke [10]. Although a number of new therapeutic agents are in development, the only antiobesity drug currently on the British National Formulary is orlistat, a lipase inhibitor, which yields a 2.5 kg or 2.9% weight reduction compared with placebo [11].
3.1.
Gastric bypass procedures
Results and discussion
Small bowel bypass procedures
The first surgical intervention for the treatment of obesity was performed in 1952 by the Swede Henrikson [12]. Limited small bowel resection, however, failed to achieve a pervasive weight loss. In 1954, Kremen et al. [13] reported a study in which canine small bowel was resected. The authors demonstrated that loss of the ileum was associated with profound fat malabsorption and significant weight loss. They later went on to perform the first bariatric operation in America. Lewis et al. subsequently described the technique of jejunocolic shunting. The results of these early malabsorptive procedures were promising with significant weight loss and no apparent adverse effects [14]. Jejunocolic and, later, jejunoileal bypass procedures became popular during the 1960s and 1970s;
As the adverse effects of small intestinal bypass procedures were beginning to become apparent, Mason and Ito [18] performed an alternative procedure, which involved horizontal division of the stomach and a loop gastrojejunostomy. This reduced gastric capacity and, by means of a tight distal anastomosis, reduced gastric outflow thereby inducing early satiety. Gastric bypass surgery avoided the adverse malabsorptive sequelae of jejunoileal bypasses and achieved an equivalent weight loss [19,20]. The Roux-en-Y modification (Fig. 1) was described in 1977 and offered several additional benefits. The replacement of the loop gastrojejunostomy with separate enteric and biliary limbs reduced the incidence of bile reflux and gastric dumping. The formation of the “Roux” loop also introduced a malabsorptive component to the procedure and reduced the jejunal loop tension and thereby reduced the risk of anastomotic leak [19,21]. Torres et al. proposed a further modification to the operative technique in 1983 with the creation of a pouch based on the lesser curvature. This offered improvements in functional reliability, vascular integrity, and technical ease [22]. Outcome data for gastric bypass surgery demonstrated a good clinical response in most patients; one early series of 227 cases reported a mean excess weight loss of 63.5% at 2 y [23]. By the beginning of the 1980s, the gastric bypass operation had become the preferred revision procedure in patients requiring operative intervention for complications associated with jejunoileal bypass [24]. Nevertheless, by removing the stomach and duodenum from continuity, gastric bypass procedures are associated with deficiencies of calcium, iron, and vitamins A, B1 (thiamine), B9 (folate), B12, D, E, and K, which can require lifelong supplementation [25].
3.3.
Banded gastroplasty
In 1971, Mason [26] trailed the horizontal division of the proximal stomach with an outflow channel along the greater
Fig. 1 e Roux-en-Y gastric bypass.
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curvature to create a small gastric pouch leaving the remaining anatomy unaltered in an attempt to avoid the adverse effects of the aforementioned bypass procedures. In these early gastroplasty procedures, the pouch was unmeasured and invariably too large and resulted in inadequate weight loss [27]. Subsequently, a number of attempts were made to stabilize the outflow channel to avoid dilatation. Gomez [28,29] described reinforcement of the outflow channel with a Dacron (INVISTA) mesh collar and, later, with a continuous polypropylene seromuscular suture. However, such modifications were troubled by outflow obstruction or suture erosion and consequent dilatation. Tretbar et al. [30] introduced the notion of a pouch based on the lesser curvature, initially by gastric plication and later by stapling when the stomach unfurled. In 1980, Mason [31] performed the first vertical banded gastroplasty; this involved a vertical staple line parallel to the lesser curvature to form a pouch 50 mL and the creation of a window through both walls of the stomach to allow the placement of a polypropylene mesh collar around the outlet (Fig. 2). Five-year follow-up data indicated that vertical banded gastroplasty achieved a sustained weight loss of 50% of the excess weight in <50% of patients. It was less effective than the gastric bypass at achieving resolution of type 2 diabetes mellitus [32]. These disappointing results led to a gradual decline in its popularity.
3.4.
Gastric banding
The quest for a simple, minimally traumatic intervention for obesity continued with the development of the gastric band. During the 1970s, Wilkinson and Peloso experimented with different restrictive techniques on canine models and, in 1978, performed the first human nonadjustable gastric band procedure [33,34]. A braided polypropylene mesh was placed around the proximal stomach to create a small-volume pouch. This was later modified through use of polyethylene (Dacron) grafts and then silicone bands [35]. Regaining weight following slippage and also the ensuing gastric outlet obstruction that resulted from erosion and stricture formation rendered these early bands impractical. In 1985, Hallberg and Forsell [36] and Szinicz et al. [37] translated experimental work with adjustable gastric bands (Fig. 3) to bariatric patients. These silicone bands were lined with a balloon that could be
Fig. 2 e Vertical banded gastroplasty.
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Fig. 3 e Adjustable gastric band.
adjusted by means of injecting or withdrawing saline from a subcutaneous port. Kuzmak [38] published a comparison of adjustable and nonadjustable bands in 1991, which demonstrated that the former achieved a mean excess weight loss of 64.3% at 3 y compared with 49.4% for nonadjustable bands.
3.5.
Biliopancreatic bypass procedures
In 1979, Scopinaro et al. [39] published the results of a trial of biliopancreatic bypass in a series of 18 patients. The procedure, which was initially developed on canine subjects, involved distal gastrectomy and division of the jejunum 250 cm proximal to the ileocecal valve. The proximal jejunum was anastomosed to the distal ileum and the distal jejunum anastomosed with the remnant stomach, creating a long biliopancreatic limb and a short enteric limb, respectively. The biliopancreatic diversion reproduced the malabsorptive effects of the jejunoileal bypass with the added restrictive effect of a partial gastrectomy but avoided the complications of the blind loop syndrome by maintaining flow of biliary and pancreatic secretions through the otherwise redundant segment. In 1993, Marceau et al. [40] described a modification of the biliopancreatic diversion (Fig. 4), which had been performed previously by Hess but was not published, involving preservation of the pylorus and proximal duodenum. In contrast to Scopinaro, a sleeve gastrectomy replaced the distal gastrectomy and the duodenal stump was returned to continuity, replacing the gastrojejunostomy. This offered a number of benefits; the biliopancreatic diversion with duodenal switch avoided postgastrectomy complications, namely dumping, diarrhea, and marginal ulceration. Scopinaro et al. [41] subsequently published outcome data for 2241 patients following biliopancreatic diversion, which demonstrated that this technique resulted in mean maintained loss of 75% of initial excess weight. In addition to this impressive remediation of obesity, biliopancreatic diversion with duodenal switch yields significant improvements in associated morbidities including 95.1% resolution of type 2 diabetes mellitus at 10 y [42].
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Fig. 4 e Biliopancreatic diversion with sleeve gastrectomy and duodenal switch.
3.6.
Sleeve gastrectomy
Johnston et al. [43] endeavored to create a safe, simple, and effective alternative to vertical banded gastroplasty and bypass procedures and, in 1987, Johnston performed the first Magenstrasse and Mill procedure. This involves the creation of a circular defect in the gastric antrum (the antral mill) just beyond the incisura angularis. Then, a tube based along the lesser curvature (the magenstrasse) is formed by stapling and dividing the stomach from the level of the defect extending proximally. Although a 40-F bougie was originally used to calibrate the diameter of the magenstrasse, this was reduced to a 32-F bougie to optimize weight loss. The technique was subsequently simplified by starting the staple line on the greater curvature, thereby negating the need for the formation of the antral defect, and the excess gastric tissue was resected. This procedure, the “sleeve gastrectomy,” had previously been performed by Marceau et al. [40] as the restrictive component of the duodenal switch procedure (Fig. 4), as previously described. The sleeve gastrectomy was initially used as the first element of a two-staged approach in high-risk patients or patients with a BMI 50 kg/m2; however, its success in achieving weight loss led to it being adopted as a primary intervention [44]. A systematic review of outcomes after primary sleeve gastrectomy reported mean excess weight loss of 60.4%, postoperative mortality of 0.17%, and a major complication rate of 6.2% [45].
3.7.
The laparoscopic era
Laparoscopic surgery has a protracted history; in 1901, Kelling [46] established a pneumoperitoneum in dogs and inserted a Nitze cystoscope directly through the abdominal wall. In the 1950s, Hopkins [47,48], a British physicist, developed the fiberscope and refined the concept in the 1960s with the invention of the rod-lens endoscope, which remains the
instrument of choice in current practice. At the same time, Semm, who later performed the first laparoscopic appendicectomy, invented a carbon dioxide insufflation device that allowed the monitoring of intraabdominal pressure and control of gas flow [49]. By the mid-1970s, the use of laparoscopy had become routine in gynecological practice; however, it was more than a decade later before the general surgeons embraced it. The advent of the laparoscopic cholecystectomy, first performed in 1985, served as a catalyst for the use of laparoscopic approaches in other general surgical procedures. The first description of a successful laparoscopic bariatric procedure was published in 1993 by Broadbent et al. [50] and reported the placement of a nonadjustable gastric band in a 16-y-old female weighing 90 kg in Australia in September of the preceding year. Catona subsequently published a series of 40 cases of laparoscopic nonadjustable band placement, the first of which was performed in February 1992. The results achieved were equivalent to those of vertical banded gastroplasty [51]. At the same time, Belachew et al. [52] developed an adjustable band that could be placed laparoscopically in a porcine model. They undertook the first laparoscopic placement of an adjustable gastric band (the LAP-BAND) in September 1993 [53]. The LAP-BAND (Allergan) was originally placed within a “retrogastric tunnel” created by dissection of the lesser curvature and of the posterior stomach [54]. This technique was associated with a high incidence of band slippage and dilatation of the gastric pouch. As a consequence of this, a “pars flaccida” approach was adopted which differed by dissection of the posterior stomach distant from, rather than in contact with, the gastric wall. The pars flaccida technique avoided the tendency to develop late pouch dilatation and was similar to that used in the laparoscopic repair of hiatus herniae [55]. A number of other adjustable bands have been developed; however, only the LAP-BAND and the REALIZE band are approved for use in America. The early 1990s saw rapid developments in laparoscopic instrumentation, including stapling devices. Hess and Hess [56] performed the first laparoscopic vertical banded gastroplasty in 1993, and later in the same year, Wittgrove and Clark [57] carried out their first laparoscopic Roux-en-Y gastric bypass. The latter was facilitated by the development of the ENDOPATH (Ethicon) Stealth circular stapler by EthiconEndosurgery. Early follow-up data from these initial laparoscopic bypasses were promising and revealed a loss of up to 101% of excess body weight at 18 mo with significant improvement in comorbidities and complete resolution of diabetes mellitus in 13 cases [58]. A number of variations in the anatomical configuration of and technique of gastrojejunostomy have subsequently been described [59]. Data comparing laparoscopic and open Roux-en-Y gastric bypass procedures indicate that the laparoscopic approach is associated with less intraoperative blood loss, a shorter hospital stay, more rapid improvement in postoperative quality of life, and equivalent loss of excess weight [60]. Additionally, laparoscopic Roux-en-Y gastric bypass is associated with a lower mortality than an open procedure (30-d mortality: laparoscopic 0.2%, open 0.5% and 30-d-2-y mortality: laparoscopic 0.1%, open 1.1%) [61]. The advent of multilumen ports and articulating instruments has resulted in the development of single-access
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laparoscopic surgery [62]. Single-access techniques have been reported for adjustable gastric bands, sleeve gastrectomy, Roux-en-Y gastric bypass, and biliopancreatic diversion [63e66]. Outcome data for these procedures remain limited and experience is restricted to only a small number of centers internationally. Nevertheless, early case series suggest that despite longer operative times, single-access bariatric surgery is more acceptable to patients, achieves equivalent weight loss, and has a similar complication rate [67].
3.8.
Endoscopic interventions
A number of bariatric procedures using an endoscopic approach have been described. The earliest of these was the intragastric balloon, which was first used in 1982 [68]. The balloon, which was deployed endoscopically, served as an artificial bezoar that created early satiety and delayed gastric emptying. Early devices were made of rubber and inflated with air; however, they failed to achieve significant weight loss and were associated with considerable morbidity [69]. Newer devices are made of silicone and filled with saline, which may be mixed with methylene blue to alert the patient to balloon rupture. The volume of the balloon can be adjusted on subsequent endoscopy and the devices may be left in place for up to 6 mo. Results with these modern devices are more promising; one large series reported mean excess weight loss of 33.9%, a complication rate of 2.8%, and two deaths (0.08%) due to gastric perforation [70]. In the past 5 y, several endoluminal devices have been developed which aim to reproduce the malabsorptive effect of bypass surgery; material from the stomach passes intraluminally although biliopancreatic secretions pass outside the sleeve [71]. The EndoBarrier (GI Dynamics) is one such device, which is inserted endoscopically and extends 60 cm from the duodenal bulb to the proximal ileum. It has been approved for use in Europe; although restrictions have been placed on the length of time, it may remain in place due to concerns regarding device migration. ValenTx (Carpenteria) is a similar device that extends from the esophagus to the proximal ileum but is not yet commercially available [72]. Limited data exist on the effectiveness of endoluminal devices but provisional
563
results with the EndoBarrier demonstrate a mean excess weight loss of 19%e22% at 12 wk with no major complications [73,74].
4.
Summary
Surgery is more effective at achieving weight loss than nonoperative interventions and is associated with significantly greater improvement of comorbidities [75,76]. A metaanalysis including a total of 135,246 patients reported that surgery for weight loss leads to complete resolution of type 2 diabetes mellitus in more than three-quarters of all patients 42. Economic analyses have demonstrated that bariatric surgery is cost-effective in patients with a BMI of 35 kg/m2 [77]. In addition, bariatric surgery reduces the number of cardiovascular deaths and is associated with a lower incidence of cardiovascular events in obese adults [78]. The Swedish Obese Subjects study assessed patients that underwent bariatric surgery (gastric bypass, adjustable gastric band, or vertical band gastroplasty) compared with matched obese controls that received nonoperative care over a median follow-up of 14.7 y. Bariatric surgery was associated with a reduced number of cardiovascular deaths (28 events among 2010 patients in the surgery group versus 49 events among 2037 patients in the control group; adjusted hazard ratio, 0.47; 95% confidence interval, 0.29e0.76; P ¼ 0.002). The number of total first time cardiovascular events was lower in the surgery group (199 events among 2010 patients) than in the control group (234 events among 2037 patients; adjusted hazard ratio, 0.67; 95% confidence interval, 0.54e0.83; P < 0.001). The significant potential for improvements in medical comorbidities after bariatric surgery has led to the issuing of guidelines on suitability for bariatric surgery. The National Institute for Health and Clinical Excellence in the UK and the National Institutes of Health in the United States both recommend that surgical intervention should be considered as an option for patients with a BMI 40 kg/m2 and patients with a BMI 35 kg/m2 in the presence of obesity-related comorbidity [6,79]. However, despite these clear directives, access to weight loss surgery remains highly variable. In the
Table e Summary of reported outcome data following bariatric surgical intervention. Procedure
Excess weight loss (%)
Effect on comorbidities
Major complications
References
Laparoscopic Roux-en-Y gastric bypass
62%e77% at 3-y postsurgery
Resolution of diabetes 82%; resolution of hypercholesterolemia 63%; resolution of hypertension 70%; improvements in GORD, sleep apnea and depression
[83e87]
Laparoscopic adjustable gastric band
44%e68% at 4 y postsurgery
Laparoscopic sleeve gastrectomy
36%e85% after up to 5-y follow-up
Resolution of diabetes 64%; resolution of hypertension 44%; improvements in GORD, dyslipidemia, sleep apnea, and depression Resolution of diabetes 66.2%; improvements in GORD, joint pain, dyslipidemia, sleep apnea, and depression
Anastomotic leak 0%e5.6%; internal herniation and or obstruction 3%e4.5%; marginal ulcers 1%e16%; mortality 0.2%e0.5% Band slippage 1.6%e2% (varies with technique); gastric erosion 0.5%e2.8%; mortality 0.05% Anastomotic leak 2.2%; strictures requiring reintervention 0.6%; mortality 0.19%
[92,93]
GORD ¼ gastroesophageal reflux disease.
[88e91]
564
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National Health Service in the UK, where health care is free at the point of access and healthcare policy is directed by government organizations, major disparities have been identified in the provision of bariatric surgical services between different geographic regions [80]. In countries where care is funded largely through health insurance and private finances, the benefits of obesity surgery may be accessible only to the more affluent members of society. This raises a challenging ethical dilemma, particularly because obesity is more prevalent among socioeconomically disadvantaged groups [81]. A further important ethical consideration with surgery for obesity is the potential for adverse outcomes. Although overall mortality rates for bariatric surgery are low, obesity increases the risk of postoperative complications and mortality [82]. To realize the long-term benefits of surgery, patients have to be motivated to sustain their weight loss. Thus, candidates for bariatric surgery must be carefully selected and appropriately counseled. A range of laparoscopic procedures have been described, which differ in their success in terms of loss of excess weight and in their complication rates (summarized in Table). Weight loss is greatest for biliopancreatic diversion followed by gastric bypass and sleeve gastrectomy and least for adjustable gastric banding. Bariatric surgery is an evolving field, which will continue to expand the given current epidemiologic trends. Developments in instrumentation and surgical techniques, including single access and natural orifice approaches, may offer further benefit in terms of patient acceptability.
Acknowledgment Financial disclosure statement: A.J.B., R.W., C.S., and A.K. have no conflicts of interest or financial ties to disclose.
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Available online at www.sciencedirect.com
journal homepage: www.JournalofSurgicalResearch.com
The evolution of minimally invasive bariatric surgery Andrew J. Batchelder, MRCS,a,b Robert Williams, FRCS DM,a,b Christopher Sutton, FRCS, MD,a,b and Achal Khanna, MRCSEd, MPhila,b,* a b
Department of General Surgery, Leicester Royal Infirmary, Leicester, UK Department of Oesophago-gastric Surgery, Leicester Royal Infirmary, Leicester, UK
article info
abstract
Article history:
Background: Obesity is a pandemic associated with significant morbidity and mortality. This
Received 17 December 2012
historical article charts the progress of successful strategies that have been used to tackle
Received in revised form
weight loss from dietary modifications to the development of surgical interventions that
3 February 2013
have subsequently evolved. It also provides a pre´cis of the reported outcome data following
Accepted 19 February 2013
minimally invasive bariatric procedures.
Available online 14 March 2013
Methods: A literature review was performed. All articles relevant to the progression of bariatric surgery and minimally invasive surgery were assessed, as were those articles that
Keywords:
described the ultimate evolution, combination, and establishment of the two techniques.
Evolution
Results: This article charts the progression of early weight loss strategies, from early dietary
Minimally invasive
modifications and pharmacologic interventions to initial techniques in small bowel bypass
Bariatric surgery
procedures, banding techniques, and sleeve gastrectomies. It also describes the simultaneous developments of endoscopic interventions and laparoscopic procedures. Conclusions: A range of procedures are described, which differ in their success in terms of loss of excess weight and in their complication rates. Weight loss is greatest for biliopancreatic diversion followed by gastric bypass and sleeve gastrectomy and least for adjustable gastric banding. Bariatric surgery is an evolving field, which will continue to expand given current epidemiologic trends. Developments in instrumentation and surgical techniques, including single access and natural orifice approaches, may offer further benefit in terms of patient acceptability. ª 2013 Elsevier Inc. All rights reserved.
1.
Introduction
Obesity is a pandemic associated with significant morbidity and mortality. Globally, a body mass index (BMI) 25 kg/m2 is the fifth leading risk factor for mortality and accounts for 44% of the burden of diabetes, 23% of the burden of ischemic heart disease, and between 7% and 41% of certain cancer burdens [1]. Data from the World Health Organization survey in 2010 estimate that 67.8% of males and 63.8% of females over the age
of 15 y in the UK have a BMI 25 kg/m2 [2]. The extent of the problem is increasing with 31% of boys and 28% of girls aged 2e15 y in England classed as overweight or obese [3]. This historical article charts the progress of strategies that have been used to tackle weight loss from dietary modifications to the development of surgical interventions that have subsequently evolved. It also provides a pre´cis of the reported outcome data following minimally invasive bariatric procedures.
* Corresponding author. Department of Surgery, Level 6 Balmoral Building, Leicester Royal Infirmary, Leicester, LE1 5WW, UK. Tel.: þ44 116 258 5247; fax: þ44 116 258 6083. E-mail address: [email protected] (A. Khanna). 0022-4804/$ e see front matter ª 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2013.02.036
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2.
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Methods
A literature review was performed. All articles relevant to the progression of bariatric surgery and minimally invasive surgery were assessed, as were those articles that described the ultimate evolution, combination, and establishment of the two techniques.
however, in 1963, the first negative results of jejunoileal bypass were reported [15]. It became apparent that small intestinal bypass was a cause of significant morbidity and mortality, with patients developing features of both short bowel and blind loop syndromes [16,17]. Such complications included bloating, arthralgia, and electrolyte imbalance due to profuse diarrhea, deficiency of fat-soluble vitamins and other micronutrients, cholelithiasis, renal calculi, and liver failure.
3.2.
3.
Dietary modification is a successful strategy for weight loss, which has been recognized for several centuries. In 1863, Banting [4], an obese English undertaker and distant relative of Frederick Banting who co-discovered insulin, reported a weight loss of 23.5 kg through adherence to a diet low in refined carbohydrates. Although not the first to highlight the benefits of such a diet, the principle contribution of Banting was to popularize the concept. Subsequently, Atwater et al. [5] invented the respiration calorimeter in 1896, enabling the measurement of energy yielded by certain foodstuffs and the notion of calorific values was conceived. The 20th century has seen the proposal of a plethora of dietary modifications for weight loss with varying degrees of success. Current guidelines recommend the consumption of a balanced diet, as described by Banting, in conjunction with regular physical activity and, where appropriate, behavioral interventions [6]. The advent of pharmacologic interventions for obesity has, however, been associated with a number of catastrophes. As early as 1893, ovine thyroid extract was trailed for weight loss with inevitable catabolic consequences [7]. In the 1930s, dinitrophenol was noted to greatly increase metabolic rate by uncoupling oxidative phosphorylation [8]. However, it was subsequently linked with the development of peripheral neuropathy and cataracts [9]. A string of other agents followed, including amphetamine, aminoxaphen, fenfluramine, and phentermine. All were linked with significant toxicities. Most recently, sibutramine was withdrawn due to increased risk of myocardial infarction and stroke [10]. Although a number of new therapeutic agents are in development, the only antiobesity drug currently on the British National Formulary is orlistat, a lipase inhibitor, which yields a 2.5 kg or 2.9% weight reduction compared with placebo [11].
3.1.
Gastric bypass procedures
Results and discussion
Small bowel bypass procedures
The first surgical intervention for the treatment of obesity was performed in 1952 by the Swede Henrikson [12]. Limited small bowel resection, however, failed to achieve a pervasive weight loss. In 1954, Kremen et al. [13] reported a study in which canine small bowel was resected. The authors demonstrated that loss of the ileum was associated with profound fat malabsorption and significant weight loss. They later went on to perform the first bariatric operation in America. Lewis et al. subsequently described the technique of jejunocolic shunting. The results of these early malabsorptive procedures were promising with significant weight loss and no apparent adverse effects [14]. Jejunocolic and, later, jejunoileal bypass procedures became popular during the 1960s and 1970s;
As the adverse effects of small intestinal bypass procedures were beginning to become apparent, Mason and Ito [18] performed an alternative procedure, which involved horizontal division of the stomach and a loop gastrojejunostomy. This reduced gastric capacity and, by means of a tight distal anastomosis, reduced gastric outflow thereby inducing early satiety. Gastric bypass surgery avoided the adverse malabsorptive sequelae of jejunoileal bypasses and achieved an equivalent weight loss [19,20]. The Roux-en-Y modification (Fig. 1) was described in 1977 and offered several additional benefits. The replacement of the loop gastrojejunostomy with separate enteric and biliary limbs reduced the incidence of bile reflux and gastric dumping. The formation of the “Roux” loop also introduced a malabsorptive component to the procedure and reduced the jejunal loop tension and thereby reduced the risk of anastomotic leak [19,21]. Torres et al. proposed a further modification to the operative technique in 1983 with the creation of a pouch based on the lesser curvature. This offered improvements in functional reliability, vascular integrity, and technical ease [22]. Outcome data for gastric bypass surgery demonstrated a good clinical response in most patients; one early series of 227 cases reported a mean excess weight loss of 63.5% at 2 y [23]. By the beginning of the 1980s, the gastric bypass operation had become the preferred revision procedure in patients requiring operative intervention for complications associated with jejunoileal bypass [24]. Nevertheless, by removing the stomach and duodenum from continuity, gastric bypass procedures are associated with deficiencies of calcium, iron, and vitamins A, B1 (thiamine), B9 (folate), B12, D, E, and K, which can require lifelong supplementation [25].
3.3.
Banded gastroplasty
In 1971, Mason [26] trailed the horizontal division of the proximal stomach with an outflow channel along the greater
Fig. 1 e Roux-en-Y gastric bypass.
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curvature to create a small gastric pouch leaving the remaining anatomy unaltered in an attempt to avoid the adverse effects of the aforementioned bypass procedures. In these early gastroplasty procedures, the pouch was unmeasured and invariably too large and resulted in inadequate weight loss [27]. Subsequently, a number of attempts were made to stabilize the outflow channel to avoid dilatation. Gomez [28,29] described reinforcement of the outflow channel with a Dacron (INVISTA) mesh collar and, later, with a continuous polypropylene seromuscular suture. However, such modifications were troubled by outflow obstruction or suture erosion and consequent dilatation. Tretbar et al. [30] introduced the notion of a pouch based on the lesser curvature, initially by gastric plication and later by stapling when the stomach unfurled. In 1980, Mason [31] performed the first vertical banded gastroplasty; this involved a vertical staple line parallel to the lesser curvature to form a pouch 50 mL and the creation of a window through both walls of the stomach to allow the placement of a polypropylene mesh collar around the outlet (Fig. 2). Five-year follow-up data indicated that vertical banded gastroplasty achieved a sustained weight loss of 50% of the excess weight in <50% of patients. It was less effective than the gastric bypass at achieving resolution of type 2 diabetes mellitus [32]. These disappointing results led to a gradual decline in its popularity.
3.4.
Gastric banding
The quest for a simple, minimally traumatic intervention for obesity continued with the development of the gastric band. During the 1970s, Wilkinson and Peloso experimented with different restrictive techniques on canine models and, in 1978, performed the first human nonadjustable gastric band procedure [33,34]. A braided polypropylene mesh was placed around the proximal stomach to create a small-volume pouch. This was later modified through use of polyethylene (Dacron) grafts and then silicone bands [35]. Regaining weight following slippage and also the ensuing gastric outlet obstruction that resulted from erosion and stricture formation rendered these early bands impractical. In 1985, Hallberg and Forsell [36] and Szinicz et al. [37] translated experimental work with adjustable gastric bands (Fig. 3) to bariatric patients. These silicone bands were lined with a balloon that could be
Fig. 2 e Vertical banded gastroplasty.
561
Fig. 3 e Adjustable gastric band.
adjusted by means of injecting or withdrawing saline from a subcutaneous port. Kuzmak [38] published a comparison of adjustable and nonadjustable bands in 1991, which demonstrated that the former achieved a mean excess weight loss of 64.3% at 3 y compared with 49.4% for nonadjustable bands.
3.5.
Biliopancreatic bypass procedures
In 1979, Scopinaro et al. [39] published the results of a trial of biliopancreatic bypass in a series of 18 patients. The procedure, which was initially developed on canine subjects, involved distal gastrectomy and division of the jejunum 250 cm proximal to the ileocecal valve. The proximal jejunum was anastomosed to the distal ileum and the distal jejunum anastomosed with the remnant stomach, creating a long biliopancreatic limb and a short enteric limb, respectively. The biliopancreatic diversion reproduced the malabsorptive effects of the jejunoileal bypass with the added restrictive effect of a partial gastrectomy but avoided the complications of the blind loop syndrome by maintaining flow of biliary and pancreatic secretions through the otherwise redundant segment. In 1993, Marceau et al. [40] described a modification of the biliopancreatic diversion (Fig. 4), which had been performed previously by Hess but was not published, involving preservation of the pylorus and proximal duodenum. In contrast to Scopinaro, a sleeve gastrectomy replaced the distal gastrectomy and the duodenal stump was returned to continuity, replacing the gastrojejunostomy. This offered a number of benefits; the biliopancreatic diversion with duodenal switch avoided postgastrectomy complications, namely dumping, diarrhea, and marginal ulceration. Scopinaro et al. [41] subsequently published outcome data for 2241 patients following biliopancreatic diversion, which demonstrated that this technique resulted in mean maintained loss of 75% of initial excess weight. In addition to this impressive remediation of obesity, biliopancreatic diversion with duodenal switch yields significant improvements in associated morbidities including 95.1% resolution of type 2 diabetes mellitus at 10 y [42].
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Fig. 4 e Biliopancreatic diversion with sleeve gastrectomy and duodenal switch.
3.6.
Sleeve gastrectomy
Johnston et al. [43] endeavored to create a safe, simple, and effective alternative to vertical banded gastroplasty and bypass procedures and, in 1987, Johnston performed the first Magenstrasse and Mill procedure. This involves the creation of a circular defect in the gastric antrum (the antral mill) just beyond the incisura angularis. Then, a tube based along the lesser curvature (the magenstrasse) is formed by stapling and dividing the stomach from the level of the defect extending proximally. Although a 40-F bougie was originally used to calibrate the diameter of the magenstrasse, this was reduced to a 32-F bougie to optimize weight loss. The technique was subsequently simplified by starting the staple line on the greater curvature, thereby negating the need for the formation of the antral defect, and the excess gastric tissue was resected. This procedure, the “sleeve gastrectomy,” had previously been performed by Marceau et al. [40] as the restrictive component of the duodenal switch procedure (Fig. 4), as previously described. The sleeve gastrectomy was initially used as the first element of a two-staged approach in high-risk patients or patients with a BMI 50 kg/m2; however, its success in achieving weight loss led to it being adopted as a primary intervention [44]. A systematic review of outcomes after primary sleeve gastrectomy reported mean excess weight loss of 60.4%, postoperative mortality of 0.17%, and a major complication rate of 6.2% [45].
3.7.
The laparoscopic era
Laparoscopic surgery has a protracted history; in 1901, Kelling [46] established a pneumoperitoneum in dogs and inserted a Nitze cystoscope directly through the abdominal wall. In the 1950s, Hopkins [47,48], a British physicist, developed the fiberscope and refined the concept in the 1960s with the invention of the rod-lens endoscope, which remains the
instrument of choice in current practice. At the same time, Semm, who later performed the first laparoscopic appendicectomy, invented a carbon dioxide insufflation device that allowed the monitoring of intraabdominal pressure and control of gas flow [49]. By the mid-1970s, the use of laparoscopy had become routine in gynecological practice; however, it was more than a decade later before the general surgeons embraced it. The advent of the laparoscopic cholecystectomy, first performed in 1985, served as a catalyst for the use of laparoscopic approaches in other general surgical procedures. The first description of a successful laparoscopic bariatric procedure was published in 1993 by Broadbent et al. [50] and reported the placement of a nonadjustable gastric band in a 16-y-old female weighing 90 kg in Australia in September of the preceding year. Catona subsequently published a series of 40 cases of laparoscopic nonadjustable band placement, the first of which was performed in February 1992. The results achieved were equivalent to those of vertical banded gastroplasty [51]. At the same time, Belachew et al. [52] developed an adjustable band that could be placed laparoscopically in a porcine model. They undertook the first laparoscopic placement of an adjustable gastric band (the LAP-BAND) in September 1993 [53]. The LAP-BAND (Allergan) was originally placed within a “retrogastric tunnel” created by dissection of the lesser curvature and of the posterior stomach [54]. This technique was associated with a high incidence of band slippage and dilatation of the gastric pouch. As a consequence of this, a “pars flaccida” approach was adopted which differed by dissection of the posterior stomach distant from, rather than in contact with, the gastric wall. The pars flaccida technique avoided the tendency to develop late pouch dilatation and was similar to that used in the laparoscopic repair of hiatus herniae [55]. A number of other adjustable bands have been developed; however, only the LAP-BAND and the REALIZE band are approved for use in America. The early 1990s saw rapid developments in laparoscopic instrumentation, including stapling devices. Hess and Hess [56] performed the first laparoscopic vertical banded gastroplasty in 1993, and later in the same year, Wittgrove and Clark [57] carried out their first laparoscopic Roux-en-Y gastric bypass. The latter was facilitated by the development of the ENDOPATH (Ethicon) Stealth circular stapler by EthiconEndosurgery. Early follow-up data from these initial laparoscopic bypasses were promising and revealed a loss of up to 101% of excess body weight at 18 mo with significant improvement in comorbidities and complete resolution of diabetes mellitus in 13 cases [58]. A number of variations in the anatomical configuration of and technique of gastrojejunostomy have subsequently been described [59]. Data comparing laparoscopic and open Roux-en-Y gastric bypass procedures indicate that the laparoscopic approach is associated with less intraoperative blood loss, a shorter hospital stay, more rapid improvement in postoperative quality of life, and equivalent loss of excess weight [60]. Additionally, laparoscopic Roux-en-Y gastric bypass is associated with a lower mortality than an open procedure (30-d mortality: laparoscopic 0.2%, open 0.5% and 30-d-2-y mortality: laparoscopic 0.1%, open 1.1%) [61]. The advent of multilumen ports and articulating instruments has resulted in the development of single-access
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laparoscopic surgery [62]. Single-access techniques have been reported for adjustable gastric bands, sleeve gastrectomy, Roux-en-Y gastric bypass, and biliopancreatic diversion [63e66]. Outcome data for these procedures remain limited and experience is restricted to only a small number of centers internationally. Nevertheless, early case series suggest that despite longer operative times, single-access bariatric surgery is more acceptable to patients, achieves equivalent weight loss, and has a similar complication rate [67].
3.8.
Endoscopic interventions
A number of bariatric procedures using an endoscopic approach have been described. The earliest of these was the intragastric balloon, which was first used in 1982 [68]. The balloon, which was deployed endoscopically, served as an artificial bezoar that created early satiety and delayed gastric emptying. Early devices were made of rubber and inflated with air; however, they failed to achieve significant weight loss and were associated with considerable morbidity [69]. Newer devices are made of silicone and filled with saline, which may be mixed with methylene blue to alert the patient to balloon rupture. The volume of the balloon can be adjusted on subsequent endoscopy and the devices may be left in place for up to 6 mo. Results with these modern devices are more promising; one large series reported mean excess weight loss of 33.9%, a complication rate of 2.8%, and two deaths (0.08%) due to gastric perforation [70]. In the past 5 y, several endoluminal devices have been developed which aim to reproduce the malabsorptive effect of bypass surgery; material from the stomach passes intraluminally although biliopancreatic secretions pass outside the sleeve [71]. The EndoBarrier (GI Dynamics) is one such device, which is inserted endoscopically and extends 60 cm from the duodenal bulb to the proximal ileum. It has been approved for use in Europe; although restrictions have been placed on the length of time, it may remain in place due to concerns regarding device migration. ValenTx (Carpenteria) is a similar device that extends from the esophagus to the proximal ileum but is not yet commercially available [72]. Limited data exist on the effectiveness of endoluminal devices but provisional
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results with the EndoBarrier demonstrate a mean excess weight loss of 19%e22% at 12 wk with no major complications [73,74].
4.
Summary
Surgery is more effective at achieving weight loss than nonoperative interventions and is associated with significantly greater improvement of comorbidities [75,76]. A metaanalysis including a total of 135,246 patients reported that surgery for weight loss leads to complete resolution of type 2 diabetes mellitus in more than three-quarters of all patients 42. Economic analyses have demonstrated that bariatric surgery is cost-effective in patients with a BMI of 35 kg/m2 [77]. In addition, bariatric surgery reduces the number of cardiovascular deaths and is associated with a lower incidence of cardiovascular events in obese adults [78]. The Swedish Obese Subjects study assessed patients that underwent bariatric surgery (gastric bypass, adjustable gastric band, or vertical band gastroplasty) compared with matched obese controls that received nonoperative care over a median follow-up of 14.7 y. Bariatric surgery was associated with a reduced number of cardiovascular deaths (28 events among 2010 patients in the surgery group versus 49 events among 2037 patients in the control group; adjusted hazard ratio, 0.47; 95% confidence interval, 0.29e0.76; P ¼ 0.002). The number of total first time cardiovascular events was lower in the surgery group (199 events among 2010 patients) than in the control group (234 events among 2037 patients; adjusted hazard ratio, 0.67; 95% confidence interval, 0.54e0.83; P < 0.001). The significant potential for improvements in medical comorbidities after bariatric surgery has led to the issuing of guidelines on suitability for bariatric surgery. The National Institute for Health and Clinical Excellence in the UK and the National Institutes of Health in the United States both recommend that surgical intervention should be considered as an option for patients with a BMI 40 kg/m2 and patients with a BMI 35 kg/m2 in the presence of obesity-related comorbidity [6,79]. However, despite these clear directives, access to weight loss surgery remains highly variable. In the
Table e Summary of reported outcome data following bariatric surgical intervention. Procedure
Excess weight loss (%)
Effect on comorbidities
Major complications
References
Laparoscopic Roux-en-Y gastric bypass
62%e77% at 3-y postsurgery
Resolution of diabetes 82%; resolution of hypercholesterolemia 63%; resolution of hypertension 70%; improvements in GORD, sleep apnea and depression
[83e87]
Laparoscopic adjustable gastric band
44%e68% at 4 y postsurgery
Laparoscopic sleeve gastrectomy
36%e85% after up to 5-y follow-up
Resolution of diabetes 64%; resolution of hypertension 44%; improvements in GORD, dyslipidemia, sleep apnea, and depression Resolution of diabetes 66.2%; improvements in GORD, joint pain, dyslipidemia, sleep apnea, and depression
Anastomotic leak 0%e5.6%; internal herniation and or obstruction 3%e4.5%; marginal ulcers 1%e16%; mortality 0.2%e0.5% Band slippage 1.6%e2% (varies with technique); gastric erosion 0.5%e2.8%; mortality 0.05% Anastomotic leak 2.2%; strictures requiring reintervention 0.6%; mortality 0.19%
[92,93]
GORD ¼ gastroesophageal reflux disease.
[88e91]
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National Health Service in the UK, where health care is free at the point of access and healthcare policy is directed by government organizations, major disparities have been identified in the provision of bariatric surgical services between different geographic regions [80]. In countries where care is funded largely through health insurance and private finances, the benefits of obesity surgery may be accessible only to the more affluent members of society. This raises a challenging ethical dilemma, particularly because obesity is more prevalent among socioeconomically disadvantaged groups [81]. A further important ethical consideration with surgery for obesity is the potential for adverse outcomes. Although overall mortality rates for bariatric surgery are low, obesity increases the risk of postoperative complications and mortality [82]. To realize the long-term benefits of surgery, patients have to be motivated to sustain their weight loss. Thus, candidates for bariatric surgery must be carefully selected and appropriately counseled. A range of laparoscopic procedures have been described, which differ in their success in terms of loss of excess weight and in their complication rates (summarized in Table). Weight loss is greatest for biliopancreatic diversion followed by gastric bypass and sleeve gastrectomy and least for adjustable gastric banding. Bariatric surgery is an evolving field, which will continue to expand the given current epidemiologic trends. Developments in instrumentation and surgical techniques, including single access and natural orifice approaches, may offer further benefit in terms of patient acceptability.
Acknowledgment Financial disclosure statement: A.J.B., R.W., C.S., and A.K. have no conflicts of interest or financial ties to disclose.
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