Not All Weight Loss Procedures Are The Same

Not All Weight Loss Procedures Are The Same

The quest to control weight through surgical intervention is not a new concept, but it is not that old compared to other surgical methods and procedures.

To understand the rationale for the various procedures that have developed through the years, it is important to have a basic understanding of how the digestive system works. The digestive tract is a hollow tube that runs from the mouth to the anus where food travels and nourishes the body. Beginning at the mouth, our teeth and saliva begin the digestive process, breaking down food and preparing it for delivery down the esophagus and into the stomach. Once in the stomach, hydrochloric acid along with digestive enzymes further break the food down into molecular-sized particles that are then delivered to the small intestine. The molecular-sized nutrients are then absorbed through the lining of the small intestine and delivered to the blood stream for distribution throughout the rest of the body. The small intestine is divided into three parts that have unique characteristics in form and function, but a common function of all three is to absorb nutrients through their lining and deliver those nutrients to the blood stream. Anything that is not absorbed by the small intestine will be delivered from the ileum to the colon where water is reabsorbed, leaving solid waste to be eliminated through defecation.

Without your small intestine, you would starve to death, but through a series of dog experiments, and indeed, through practical experience with a number of human patients who had various diseases of the small intestine requiring partial removal, it became evident that we can live quite healthy lives with only a fraction of our small intestine.

In a 1952 case report, Dr. Viktor Henrikson of Sweden described the removal of approximately 3.5 feet of small intestine in a woman who suffered from chronic constipation and obesity. Although the procedure failed to produce any significant weight loss, medical historians credit Dr. Henrikson with performing the first surgical procedure specifically for weight loss.

Weight loss procedures are generally classified as either restrictive, malabsorptive, or a combination of the two. Restrictive operations restrict the size of the stomach so you cannot physically hold as much food and thus restrict the amount of food consumed in any one meal. Malabsorptive procedures inhibit the amount of nutrients absorbed through the lining of the small intestine.

Early procedures focus on interfering with the absorption of nutrients (and calories). The jejunoileal bypass was based on the concept that by excluding a majority of the small intestine, the patient would absorb only a fraction of the food they ate and would thus lose weight. Although patients did lose substantial amounts of weight, mild to serious complications developed in up to two thirds of patients including bloating, chronic diarrhea with electrolyte abnormalities, arthralgias (painful joints), vitamin and mineral deficiencies and protein malnutrition, with the most serious complication being cirrhosis with liver failure in up to 5% of patients. Ultimately, a life-saving reversal of the bypass was necessary in a significant number of these patients.

One of the major problems with the original jejunoileal bypass was a condition known as bacterial overgrowth syndrome (also known as blind loop syndrome). Bacterial overgrowth syndrome results from a large portion of the small intestine being defuntionalized. In other words, no food is passing through this portion of the small intestine so it is not functioning in the capacity for which it was designed. Over the next couple of decades, surgeons developed alternatives to the jejunoileal bypass in an effort to overcome the problem of bacterial overgrowth syndrome.

Two of these alternative procedures were the Bilopancreatic diversion (BPD) and the Gastric Bypass Procedure.

As the jejunoileal bypass began to fall out of favor, weight loss surgeons changed their focus away from procedures that interfered with the absorption of nutrients to procedures that would restrict the amount of food consumed during a single meal. “Restrictive only” procedures avoided some of the nasty side effects encountered in the malabsorptive procedures such as diarrhea and vitamin deficiency. This reduced the amount of food consumed at one time and thus, the thinking was, would reduce calorie consumption and lead to weight loss.

While the many variations of restrictive only procedures succeeded in avoiding the problems with malabsorption, they did so at the cost of failed weight loss. Patients would lose weight, but five to 10 years later, most would regain their weight and another failed era of weight loss surgery would soon end with one exception, the Lap-Band.

The Laparoscopic Adjustable Gastric-Band has remained very popular, but it too had a rocky start as the precursors to the adjustable band resulted in dismal failures. Unfortunately, the high incidence of scarring, band erosion and other malfunctions of these bands led to the development of new and improved versions that would later evolve into the modern day Lap-Band.

In its brief history, bariatric surgery has gone through a substantial evolution. From the jejunoileal bypass that relied on malabsorption alone to the non-adjustable band that relied on restriction alone, or the gastric bypass with its combination of the two, these procedures represent the surgeons’ quests to treat a condition that appeared to have no good medical cure. These pioneers of surgery have paved the way to modern day procedures. Three important factors have slowly begun to change negative attitudes towards these procedures.

  1. The explosive growth of obesity has created a sense of urgency, forcing doctors of all specialties to explore all reasonable options for addressing this major health issue.
  2. A better understanding of the nature of obesity as a metabolic disease rather than strictly a behavioral problem or character flaw.
  3. The development of the laparoscopic approach to bariatric surgery provides faster recovery times, shorter hospital stays, and fewer deaths and complications.

While overall acceptance for bariatric surgery has improved over the past decade, a fierce battle continues among surgeons to find the perfect operation.

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