Very few surgical specialties can boast of the meteoric rise that bariatric surgery has seen over the past two decades. As more and more data is emerging on the metabolic aspect of this surgery, future for practitioners of this type of surgery promises to be even more exciting. However it is not a new specialty and there are lessons that can be learnt from the past. We explore here the current status of bariatric surgery, its journey so far and make an attempt to look into the future.
We are living through a worldwide epidemic of obesity and Type II Diabetes Mellitus. Though bariatric Surgery has been around for more than 60 years, it has only recently gained widespread attention. Its beneficial role extends beyond the significant weight loss into improvement of almost every single organ function. Radical improvement in Type II Diabetes Mellitus, Hypertension, Hyperlipidaemia, Sleep Apnoea, COPD, Arthritis, Reflux etc have been known for some time. More recent studies indicate improvement in renal parameters, cardiac function and even mental faculties. Furthermore, there is some evidence that bariatric surgery reduces mortality  and leads to a decreased incidence of cancers in women . Over the last two decades, bariatric surgery has reinvented itself on the back of developments in laparoscopic surgery, improved safety profile of procedures, and increased understanding of its role in amelioration of a range of medical conditions associated with obesity.
Bariatric Surgery: The Present
In 2008, 344,221 bariatric operations were performed worldwide by 4,680 bariatric surgeons, 220,000 of which were performed in USA and Canada by 1,625 surgeons. The most commonly performed procedures were LAGB (Laparoscopic Adjustable Gastric Banding) in 42.3% patients, LRYGB (Laparoscopic Roux-en-Y Gastric Bypass) in 39.7% patients, and LSG (Laparoscopic Sleeve Gastrectomies) in 4.5% patients . Asia, as expected, has lagged behind a bit . The absolute number of procedures in Asia increased from 381 to 2091 over a 5 year period from 2004 to 2009, an increase of 5.5 times. LSG increased from 1% to 24.8% over this period and LRYGB from 12% to 27.7%. On the contrary, numbers of LAGB and MGB decreased from 44.6% to 35.6% and 41.7% to 6.7%, respectively. Even with the declining numbers, LAGB remained the most commonly performed procedure in Asia over the study period followed by LRYGB. LRYGB is probably the gold standard bariatric procedure at present with LSG rapidly gaining in popularity. With short term weight loss not far inferior to LRYGB and a better safety profile, LSG is rapidly becoming an attractive option for suitable patients. Severe gastro-oesophageal reflux (usually in conjunction with hiatus hernia) with or without Barrett’s oesophagus are the only absolute contraindications for LSG in our practice. There are some concerns with regards to durability of this procedure in the longer term. Other procedures currently being performed include BPD (Bilio Pancreatic Diversion) and DS (Duodenal Switch). These are however currently only being performed by enthusiastic surgeons in selected centres. Of the endoscopic procedures available, Gastric Balloon is the only widely used procedure currently. However it is a temporary option and the usual treatment period is 6 months, at the end of which balloon has to be removed. We use it for selected indications in our practice, the most important being to get the weight down to a level where a safer surgery can be carried out.
Bariatric Surgery: The Past
A quick look at the history of bariatric surgery would reveal that the procedures have mainly evolved along three lines, ones that interfere with the intake of calories (Restrictive procedures), those that interfere with its absorption (Malabsorptive procedures) and a combination of these two approaches. Some of these procedures also owe their success to the neural and hormonal changes that are only now beginning to be studied in some depth.
Purely Malabsorptive Procedures:
Jejuno-Ileal Bypass: The first reported bariatric procedure, jejuno-ileal bypass by AJ Kremen and colleagues in 1954 , was a purely malabsorptive procedure. Several modifications of this procedure were tried. Despite satisfactory weight loss, significant malabsorption with its resultant nutritional problems has meant that jejuno-ileal bypass is no longer an acceptable bariatric procedure .
Combined Restrictive and Malabsorptive Procedures:
Problems with purely malabsorptive procedures led to the development of a whole range of combined procedures using some restriction in stomach capacity in conjunction with varying degrees of malabsorption. Such combination reduced reliance on malabsorption to achieve weight loss. Gastric Bypass, BPD (Bilio Pancreatic Diversion) and DS (Duodenal Switch) were developed on the back of these ideas.
Gastric Bypass: The first gastric bypass was reported by Mason and Ito in 1967 from University of Iowa . Several modifications over past few decades have led to the development of RYGB (Roux-en-y Gastric bypass) as we know today. Initial loop gastric bypasses performed with a transversely placed gastric pouch high up in the fundus were discarded in favour of roux-en-y configuration using a small lesser curvature based pouch due to perceived problems with biliary reflux. However with MGB (Mini Gastric Bypass) as developed by Rutledge  using a lesser curvature based longer gastric pouch, loop bypass is making a comeback. RYGB (Proximal), as it is commonly performed, results in little malabsorption. Its variant called Distal Gastric Bypass produces more significant malabsorption. However there is no evidence currently to say Distal Gastric Bypass is superior to Proximal Gastric Bypass . Distal Very long Roux-en-Y Gastric Bypass has also been reported with satisfactory medium term results . Wittgrove reported first LRYGB in 1994 . Since then the laparoscopic approach has evolved to become the preferred option.
Bilio-Pancreatic Diversion and Duodenal Switch: These procedures were developed based on the realisation that some patients will not lose enough weight with gastric bypass and others will regain it years later. A more aggressive procedure was needed. Scopinaro published his first experience with his BPD in 1979 . This operation involved a distal gastrectomy and an anastomosis between proximal stomach and small bowel to maintain continuity of gastrointestinal tract. When Drs. Hess and Hess started performing this operation in their practice, they found marginal ulceration to be a problem with this procedure. Inspired by the duodeno-jejunal anastomosis performed by DeMeester et al  for patients with duodenogastric reflux, Hess and Hess performed first DS operations in the world and published their series of440 patients undergoing BPD with a DS in 1998. Gastrectomy was performed leaving behind a lesser curvature based sleeve of the stomach. This enabled an anastomosis between duodenum and small bowel. Gagner performed the first laparoscopic DS in the world and published his experience in 2000 . Of the combined restrictive and malabsorptive procedures, BPD and DS use more malabsorption and thus achieve higher and more reliable weight loss. However, higher weight loss with BPD and DS comes at the cost of increased morbidity and mortality. This along with the fact that these operations are technically challenging to perform may be the reasons why they have not been adopted so widely.
Mini (Omega Loop) Gastric Bypass: In an attempt to make gastric bypass safer, Rutledge developed MGB which used a longer gastric pouch and a loop gastrojejunostomy at approximately 200 cms from duodeno-jejunal flexure thus obviating the need for a jejuno-jejunostomy. He performed first MGB in 1997 and reported his extensive experience with 1024 patients in 2001 . Earlier concerns with biliary reflux and risk of malignancy  seem to have subsided to some extent and thousands of procedures have now been performed worldwide [17-19].
All of the above combined procedures carry small but significant morbidity and mortality in addition to the adverse nutritional consequences. This has prompted surgeons to look for safer alternatives. Purely restrictive operations (Vertical Banded Gastroplasty, Adjustable Gastric Banding, Sleeve Gastrectomy etc.) developed on the back of these concerns.
Purely Restrictive Procedures:
Jaw Wiring: Jaw Wiring has to be described as the first purely restrictive procedure performed. As early as 1977 Rodgers et al published their experience with 17 cases . However the procedure never caught on presumably due to weight regain and lack of patient acceptance.
Vertical Banded Gastroplasty: Search for an effective restrictive procedure which would be as effective as gastric bypass but with less adverse effects and complications led Mason to develop gastroplasty . A series of attempts and modifications followed culminating ultimately into VBG (Vertical Banded Gastroplasty). Mason reported his first experience with 42 patients in 1982 . Problems with band, staple line disruption, and technical difficulties in revising this procedure have meant that it is no longer carried out.
Adjustable Gastric Banding: Problems with VBG led to the development of AGB (Adjustable Gastric Band) with Kuzmak reporting first adjustable gastric band in 1990 . Over the last two decades this operation has undergone many changes with regards to surgical approach (open giving way to laparoscopic), technique (pars flaccida technique as opposed to perigastric technique) and the characteristics of the prosthesis (low pressure vs high pressure, narrow vs wide) and inflation port. Technical ease with which the operation can be carried out and high patient acceptance (due to low perioperative mortality, patient perception of it being less drastic, and reversibility) have meant that it is now the most commonly performed bariatric operation globally. This is despite dismal results reported by many in the long term [24-26]. Others however have had better experience . In their desperate search for an operation with durable long term results, surgeons have combined gastric bands with other procedures. Banded bypass and sleeves have been advocated [28-29] but with limited uptake. Very few surgeons would today perform banded duodenal switch .
Magenstrasse and Mill Procedure: Johnston et al  attempted to overcome several of the problems associated with vertical banded gastroplasty and adjustable gastric banding by designing this operation, but the procedure did not find widespread acceptance due probably to unsatisfactory weight loss. In their further paper , this group conceded that even though they obtained 63% excess weight loss at one year, there was no further weight loss beyond this point and in some patients, the weight actually started rising. In this paper, authors modified their procedure by combining it with RYGB. Others have tried a different modification . By and large, this procedure has now been taken over by LSG even though the comparison is a bit unfair as there are several fundamental differences between the two.
Sleeve Gastrectomy: The history of sleeve gastrectomy is that of a gradual evolution. First sleeve gastrectomy was probably performed by Hess and Hess as a part of their Duodenal Switch procedure . Gagner’s team  reported their feasibility study of laparoscopic approach for this procedure in 2001. Sleeve gastrectomy gradually found acceptance following good results as a first stage procedure for high risk patients undergoing BPD/DS [35-36]. Kirk’s rat experiments  and Tretbar’s gastric plication  may have had a role in the thinking behind sleeve gastrectomy and gastric plication. Whereas sleeve gastrectomy has now got established as a standalone procedure with significant promise, gastric plication must be considered investigational at present [39-40].
Bariatric Surgery: The Future
Purely malabsorptive procedures are dead and predominantly malabsorptive combined procedures are not finding enough support. On the other hand predominantly restrictive combined procedures and purely restrictive procedures are becoming more and more popular. It would appear that there is an increasing appetite amongst patients and surgeons for less risky procedures even if it comes at a cost of less weight loss. Direction of travel of bariatric surgery seems to be towards safer options. Any future innovation in this area would have to take this into account and put safety first. At the same time, one must not forget that options that seem safer in the short term may not be so in the long term. LAGB could be placed into this category. LSG and LMGB, on the other hand, are showing significant promise. Development of safer and better procedures will require a better understanding of obesity and its mechanisms and a better insight into currently effective procedures. A fuller understanding of neural and hormonal pathways regulating appetite and satiety will not only help us plan our surgeries better but could also potentially pave way for development of better pharmacological strategies. Since obesity is such a big public health issue, governments and charities should fund a lot more research than is currently happening.
LAGB: Laparoscopic Adjustable Gastric Banding
LRYGB: Laparoscopic Roux-en-Y Gastric Bypass
LSG: Laparoscopic Sleeve Gastrectomy
LMGB: Laparoscopic Mini Gastric Bypass
BPD: Bilio Pancreatic Diversion
DS: Duodenal Switch
RYGB: Roux-en-Y Gastric Bypass
MGB: Mini Gastric Bypass
VGB: Vertical Banded Gastroplasty
AGB: Adjustable Gastric Banding
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