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1 COSMETIC A Review of Bariatric Surgery Procedures Morbid obesity is a chronic condition that is extremely difficult to treat. In addition to unhealthy food choices and lifestyles, effective treatment for morbid obesity is complicated by such factors as genetics and complex behavioral issues, which are not fully understood. Although diet and exercise remain the first choices in obesity therapy, they are rarely successful in achieving long-term weight loss. Adequate pharmacologic intervention remains elusive, and even among patients who do achieve weight loss through diet and exercise and/or pharmacologic intervention, only a low percentage actually maintain this loss for any significant period of time. 1,2 Bariatric surgery is currently the only therapy effective at achieving weight loss with significant improvement or resolution of comorbidities. 3 It is important that plastic surgeons planning body contouring surgery on massive weight loss patients understand the varying physiological effects these different procedures have on the body. Despite losing massive amounts of weight with significant overall improvements in health, these patients differ physiologically as compared with normal-weight individuals. Bariatric procedures are typically classified as restrictive, malabsorptive, or a combination of both. Purely malabsorptive procedures, the earliest bariatric surgeries performed, interrupt the digestive process, whereas restrictive procedures, as the name implies, restrict food intake by altering the size of the stomach. The more common techniques used today involve a combination of both restriction and malabsorption. While these procedures are highly effective in helping patients achieve and maintain weight loss, the patients are at risk for lifelong problems, such as anemia and other nutritional deficiencies, that can ultimately affect the outcome of body contouring surgery. HISTORY Bariatric surgery first began in the 1950s and evolved from the experiences of general surgeons who had to remove segments of patients small Received for publication July 6, 2005; revised October 22, Copyright 2005 by the American Society of Plastic Surgeons DOI: /01.prs d intestines because of disease and/or necrosis. It was noted that patients who experienced shortgut syndrome, defined as removal of a significant portion of the small intestine, lost weight after their operation. This was attributed to a decrease in the total absorptive surface area of the remaining intestine, which caused malabsorption of food. Different segments of the small intestine are responsible for the absorption of vitamins, minerals, fats, proteins, and other nutrients, thus patients with short-gut syndrome often experience some type of vitamin and mineral deficiencies or diarrhea due to food not being absorbed and/or digested properly. Early bariatric surgical procedures experimented with variations of the shortgut syndrome, and although patients lost weight, severe side effects began to emerge that motivated surgeons to enhance and improve their technique. Much of the early research done on the role of the small intestine in digestion and absorption, as well as on bariatric surgery, took place at the University of Minnesota. It was there, in the early 1950s, that Dr. Richard L. Varco performed one of the first jejunoileal bypass procedures. In this procedure, the proximal small intestine is joined to the distal large intestine, bypassing a large section of the lower bowel. In 1954, Kremen et al. 4 published the first article on bariatric surgery to appear in a peer-reviewed journal, presenting the results of a jejunoileal bypass procedure they had performed. Concurrently, surgeons in Sweden reported using a similar procedure, although they excised, rather than bypassed, portions of the small intestine. The 14 4, or end-to-side, jejunoileal bypass was described by Payne and DeWind 5 and was a very popular technique for 15 to 20 years. In this procedure, the first 35.6 cm of the jejunum was connected to the last 10.2 cm of the ileum, thus reducing the absorptive stream from 345 to 546 cm to 45.7 cm. Although the jejunoileal bypass caused nutritional deficiencies, mineral and electrolyte imbalances, and frequent diarrhea, patients succeeded in losing weight. As these patients were followed (for 10 to 20 years after surgery), more serious problems began to emerge, including acute hepatic failure, cirrhosis, and even death. It was determined that these more lifethreatening issues were due to the overgrowth of bacteria in the bypassed small intestine, where 8S

2 Volume 117, Number 1S Bariatric Surgery Procedures migration into the portal venous system and beyond caused serious problems. Approximately 5 percent of patients died during the first postoperative year after these early, short-gut procedures, and it is estimated that as many as 30 to 50 percent of patients developed cirrhosis within 25 years of surgery. Because of the serious nature of these adverse events, the jejunoileal bypass is no longer a recommended bariatric surgery procedure. The next major development in malabsorptive bariatric procedures began to emerge in the 1970s. Dr. Nicola Scopinaro of Italy developed a procedure known as the biliopancreatic diversion. This procedure differed from the jejunoileal bypass in that much less of the small intestine was rendered nonfunctional, resulting in fewer liver problems. Over time, significant modifications to the procedure have taken place. Today, this surgery involves two steps. In the first step, a limited gastrectomy is performed to reduce the stomach capacity by a third, to 118 to 148 cc. In the second part of the procedure, a long biliopancreatic or malabsorptive limb is created, with a 50-cm common channel for absorption (Fig. 1). One serious nutritional complication with biliopancreatic diversion is that of protein-calorie malnutrition, which, on occasion, may require total parenteral nutrition. Other complications include anemia and bone demineralization. Of the current bariatric procedures in use, the biliopancreatic diversion is the most complex and induces the greatest degree of malabsorption, which accounts for its success in maintaining weight loss. Some patients tend to favor this operation because requirements are minimal in terms of dietary modification. Recent data from Dr. Scopinaro indicate that 72 percent excess body weight loss is maintained for 18 years. In terms of the amount and duration of weight loss, these results are the best that have been published to date. 6 A modification of the original biliopancreatic diversion, the biliopancreatic diversion with duodenal switch, evolved under the guidance of Canadian surgeon Dr. Picard Marceau and his colleagues in Canada. This technique incorporates a sleeve gastrectomy, leaving the pylorus of the stomach intact (Fig. 2). The reported advantage of the duodenal switch in this procedure is the elimination of stomal ulcer formation and dumping syndrome. (Dumping syndrome is a physiologic reaction in which certain foods that are typically high in sugar content cause dumping, characterized by symptoms of nausea, flushing and sweating, light-headedness, and watery diarrhea.) Although these largely malabsorptive procedures help bring about significant weight loss, they place patients at highest risk for long-term nutritional deficiencies and require careful long-term follow-up. In addition, most patients will experience an undesirable side effect of frequent, foulsmelling stools. The biliopancreatic diversion, therefore, has not gained widespread use. Fig. 1. Scopinaro biliopancreatic bypass (BPB), with the limbs identified. BPD, biliopancreatic diversion. Fig. 2. Biliopancreatic bypass with duodenal switch (BP:DS). 9S

3 Plastic and Reconstructive Surgery January Supplement 2006 Dr. Edward Mason of the University of Iowa took a different approach in 1966 and developed what has now become known as the gastric bypass, Roux-en-Y gastric bypass, or RYGB. In this procedure, both the size of the stomach and the outlet from the reduced stomach are restricted. This significantly reduces the amount of food a patient is able to consume. The gastric bypass utilizes a lesser degree of malabsorption, in which the new stomach pouch is connected to a section of the jejunum, bypassing the distal stomach, all of the duodenum, and some of the proximal jejunum. The earliest forms of gastric bypass were referred to as loop gastric bypass. This was later modified because the loop aspect of the procedure allowed for severe reflux of bile and other digestive juices into the esophagus, with subsequent irritation and ulcer formation. Recently, this procedure has resurfaced at a small number of centers, where it is performed laparoscopically and referred to as the mini gastric bypass. These patients, however, continue to be at risk for alkaline gastritis and possibly a higher incidence of esophageal dysphagic changes. Dr. Ward Griffen developed a modification of the gastric bypass procedure by replacing the loop aspect with a Roux-en-Y gastrojejunostomy (Fig. 3). The general term gastric bypass now refers to the Roux-en-Y technique, in which the small intestine is reconfigured into aywithtwo limbs (Roux and biliopancreatic) and a common channel. A thumb-sized stomach pouch is created by stapling just below the esophagus. The jejunum is divided approximately 30 cm below the stomach, and the new pouch is connected to the Roux limb, also known as the alimentary tract. The gastric remnant, duodenum, and first portion of the jejunum drain via the biliopancreatic limb, with the digestive juices (gastric secretions, bile, and digestive enzymes) entering the common channel distally. This modification reduces or eliminates the problem of bile-induced gastritis seen in the loop gastric bypass. One variant of the gastric bypass, the long-limb gastric bypass, utilizes a greater degree of malabsorption, with a biliopancreatic limb of at least 150 cm and with consequences more like those of the biliopancreatic diversion. The difference is that the long-limb gastric bypass uses the jejunum as an alimentary tract, whereas the ileum serves this function in the biliopancreatic diversion. Due in large part to fewer postoperative complications and durable long-term weight loss, gastric bypass has quickly become the most commonly performed bariatric procedure. Fig. 3. Roux-en-Y gastric bypass with a retrocolic, retrogastric Roux limb via a laparoscopic procedure. PURELY RESTRICTIVE PROCEDURES In an attempt to eliminate the long-term effects of malabsorption, Dr. Mason and others worked on developing purely restrictive bariatric procedures. This led to a procedure known as the vertical banded gastroplasty (Fig. 4). In this procedure, a circular window is made through the stomach a few inches below the esophagus. A surgical stapler is used to create a small vertical pouch by putting a row of staples from the window toward the esophagus. The pouch is carefully measured to hold approximately 15 ml of solid food. A polypropylene Fig. 4. Vertical banded gastroplasty. 10S

4 Volume 117, Number 1S Bariatric Surgery Procedures band is placed through the window, around the outlet of the pouch, and secured to itself. The band controls the size of the outlet and keeps it from stretching. The greatest advantage of the vertical banded gastroplasty is the elimination of malabsorption to achieve weight loss. Complications include esophageal reflux and stomal narrowing or widening, which may require reoperation. Although longterm weight loss is respectable with vertical banded gastroplasty, results are not as successful as those seen with the gastric bypass. MODERN TRENDS Modifications to the vertical banded gastroplasty technique continued to be developed, and in the mid-1980s, Kuzmak 7 and Forsell et al. 8 separately described techniques that utilized different types of adjustable gastric bands (Fig. 5). In Kuzmak s technique, a ring is placed around the top end of the stomach just below the junction of the stomach and esophagus, using an adjustable band. The lining of the band is an inflatable balloon connected to a small reservoir placed subcutaneously. The balloon can be inflated, which allows for adjustment of the diameter and creation of a pseudopouch. This procedure is purely restrictive, as it allows food to go through a normal digestive process. At the present time, the only adjustable gastric band available for use in the United States is the BioEnterics Lap-Band System (BioEnterics Corporation, a division of Inamed Corporation, Santa Barbara, Calif.). This product has completed Food and Drug Administration trials and was approved for use in the United States in June of The Swedish Adjustable Gastric Band (Ethicon Endo- Surgery, Inc., a division of Johnson & Johnson, New Brunswick, N.J.), in use in Europe for many years, is expected to be approved for use in the United States in the near future. There are many advantages to the adjustable gastric band, including the fact that it is less invasive and associated with a lower mortality rate. The procedure is reversible: if the band is removed, the stomach returns to its original shape within days. One important advantage lies in longterm adjustability, which can help maximize weight loss while minimizing adverse symptoms. The band can be loosened during pregnancy, which allows greater flexibility for women who are considering having children. Early trials with adjustable lap bands in the United States were met with a high complication rate, but as insertion techniques have changed and more experience has been gained with band adjustment, the results with weight loss have improved. 9 Weight loss is slower with the adjustable lap band compared with bypass procedures. This results in a significantly longer period of time for patients to achieve their ideal weight. However, with a significant reduction in operative risk and improving results, the adjustable gastric band may become the bariatric procedure of choice. GASTRIC BYPASS VERSUS BANDING PROCEDURES: OPEN VERSUS LAPAROSCOPIC GASTRIC SURGERY Bariatric surgical procedures can be completed in most patients with either laparoscopic or open techniques. From 2002 to 2003, 63 percent of bariatric procedures worldwide were performed laparoscopically. It is estimated that more than 110,000 adjustable gastric bands have been Fig. 5. Adjustable gastric band. 11S

5 Plastic and Reconstructive Surgery January Supplement 2006 placed laparoscopically (worldwide) since In the United States, however, gastric bypass still accounts for the vast majority of weight loss surgery procedures, with the most common being some form of the Roux-en-Y gastric bypass procedure. Adjustable lap bands, although gaining popularity in the United States, are not covered by most insurance companies, thus limiting their current usage. As more safety and efficacy data on lap band outcomes are gathered, and as surgeons gain more experience with these new devices, there will most likely be a continued increase in the number of gastric banding procedures performed in the United States (Fig. 6 and Table 1). Fig. 6. Spectrum of bariatric procedures. Courtesy of Jeffrey L. Sebastian, M.D. All rights reserved. Table 1. Bariatric Surgery: Procedure Review Date Introduced Name M/R Description Comments 1954 Jejunoileal bypass Mid-1970s Vertical banded gastroplasty M Upper small intestine joined to lower part of intestine bypassing large section of lower bowel R Create a pouch that holds cc; current technique, cc 1970s 1980s Gastric stapling R & M Volume of stomach reduced by stapling upper portion 1977 Roux-en-Y R & M Thumb-size pouch created by stapling off upper portion of stomach 1979 Biliopancreatic diversion 1988 Duodenal switch 1990s Adjustable gastric banding M/R, malabsorptive/restrictive. 12S R & M R & M R Similar to Roux-en-Y, creates a stomach pouch and bypasses part of small intestine Portion of the duodenum is bypassed from digestive continuity Ring placed above top end of stomach using inflatable band Small intestine reduced from 610 cm to 46 cm; patients experienced diarrhea, mineral and electrolyte imbalance, and liver cirrhosis; high mortality rate - discontinued Cannot be adjusted without additional surgery if problems exist Opening of band stretches, reducing initial weight loss Small size limits food intake Larger pouch than Roux-en-Y May be covered by some insurance plans Continues to improve with availability of new and improved adjustable lap bands; weight loss not as dramatic as with other bariatric procedures

6 Volume 117, Number 1S Bariatric Surgery Procedures REFERENCES 1. North American Association for the Study of Obesity and the National Heart, Lung, and Blood Institute. The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults (NIH Publication No ). Bethesda, Md.: National Institutes of Health, North American Association for the Study of Obesity (NAASO) and the National Heart, Lung, and Blood Institute. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report (NIH Publication No ). Bethesda, Md.: National Institutes of Health, Buchwald, H., Avidor, Y., Braunnald, E., et al. Bariatric surgery: A systematic review and meta-analysis. J.A.M.A. 292: 1724, Kremen, J. A., Linner, L. H., andnelson, C. H. An experimental evaluation of the nutritional importance of proximal and distal small intestine. Ann. Surg. 140: 439, Payne, J. H., anddewind, L. T. Surgical treatment of obesity. Am. J. Surg. 118: 141, Scopinaro, N., Adami, G. F., Marinari, G. M., et al. Biliopancreatic diversion: Two decades of experience. In M. Deital and S. M. Cowan, Jr. (Eds.), Update: Surgery for the Morbidly Obese Patient. Toronto, Canada: FD Communications, Pp Kuzmak, L. I. Silicone gastric banding: A simple and effective operation for morbid obesity. Contemp. Surg. 28: 13, Forsell, P., Hallberg, D., and Hellers, G. Gastric banding for morbid obesity: Initial experience with a new adjustable band. Obes. Surg. 3: 369, Buchwald, H. Bariatric surgery worldwide. Obes. Surg. 14: 1157, S

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