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Obesity has become a severe problem in the United States of almost epidemic proportions. Nearly 5 percent of the U.S. population, or about 10 million people, meet NIH/ASBS eligibility criteria for weight loss surgery, which include a willingness to make a commitment to a lifestyle change; a BMI of 35 with comorbidities, or a BMI of 40 or greater without comorbidities; plus a history of previous attempts at medical weight loss.
Millions of Americans have found that diet, exercise and pharmacologic methods alone are not sufficient to combat and eliminate their excess weight. Often, years of failed dieting have changed a patient's metabolism, making it more difficult to lose weight and keep it off.
According to the NIH's 1991 Consensus Conference Statement, only surgery has proven effective over the long-term for most patients with clinically severe obesity. With improved surgical methods, more patient education, and effective support systems in place, more Americans are considering surgery as a viable option.
The public success stories of celebrities and others have added to the popularity of the surgery, which has evolved over the past 50 years. When Kremen and associates performed the first bariatric procedure in 1954, it involved anastomosis of the upper and lower intestine, which bypasses a large amount of the absorptive circuit. Later Jejuno-colic Shunt, developed in 1963 by Payne, DeWind, which connected the upper small intestine to the colon, followed this Jejuno-ileal bypass. Patients experienced uncontrollable diarrhea, and the procedure was converted to end-to-end anastomosis to alleviate symptoms. Modifications to the procedure included the 1973 Scott, Dean technique of bypassing smaller lengths of small intestine. This led to severe diarrhea, dehydration and a third of patients developing hepatic cirrhosis.
In 1996, Scopinaro, Gianetta et al developed what is now one of the most common procedures: Bilio-pancreatic Diversion, a limited gastroectomy with long limb Roux-en-Y and a short common alimentary canal. This procedure produces significant malabsorption, but long-term studies demonstrate 72 percent of excess weight loss maintained over an 18-year observation. The addition of a Duodenal Switch by Hess, Marceau in 1992-1993 eliminated stomach ulcers and dumping syndrome. Such malabsorptive procedures produce greater sustained weight loss with less dietary compliance, but pose an increased risk of malnutrition, vitamin deficiency and intermittent diarrhea, and require constant follow up to monitor increased risk.
Mason, Ito et al. developed the Gastric Bypass in 1967, which led to fewer complications than the intestinal bypass. The procedure involves a stapled stomach and a bypassed small intestine. Complications included anastomotic leaks, peritonitis, outlet stenosis, anemia, and vitamin deficiencies. A later improvement, the Roux-en-Y Gastric Bypass, proved technically difficult to perform but led to long-term sustained weight loss, no protein-calorie malabsorption and little vitamin or mineral deficiencies. The surgeon cuts a small 15 to 20 cc pouch at the top of the stomach, divides the small bowel, and then reattaches the biliopancreatic limb to the small bowel while the other end is connected to the pouch, creating the Roux limb. The small pouch releases food slowly, creating the sensation of fullness, and the biliopancreatic limb preserves the action of the digestive tract.
Gastroplasty, including gastric banding pioneered by Kuzmac, Yap in 1990, used an inflatable gastric band to create an hourglass stomach. While it is a relatively easy surgical procedure, long-term success depends on having a high degree of patient compliance.
As surgical tools and procedures continue to improve and obesity rates rise, the medical community can expect greater interest in bariatric surgery and greater understanding from the general population. While the methodology has improved, PCPs and surgeons still face the same challenge of educating their patients about the permanent and life-altering ramifications of this procedure. Patient education will take on increasing importance as a higher percentage of the population begins to consider bariatric surgery as a tool for significant weight loss.
(information was provided by www.autosuturebariatrics.com)