History of the development of bariatric surgery

Bariatric surgery - is the methods of surgical (surgical) treatment of obesity. The development of bariatric surgery began in the early 50s of the 20th century. Over the next 40 years, more than 50 different types of surgical interventions for the treatment of obesity have been proposed. To date, there are 4 main methods of surgical treatment:

• • operations aimed at reducing the area of the intestinal suction surface (shunting operations - in-line shunting). The intestine is the place of absorption of nutrients entering the human body. With a decrease in the length of the intestine through which the passage takes place, or the passage of food, the effective functional surface of the gut decreases, and the absorption of nutrients decreases, and less enters the blood.
  • operations aimed at reducing the suction surface of the stomach - gastroshuntirovanie. The mechanism of this operation is the same. Only turn off the process of absorption is not the gut, but the stomach. This changes the shape of the stomach.
  • operations aimed at a significant reduction in gastric volume - gastro-restrictive. With these operations, the stomach size is changed, which leads to a decrease in its volume. It is known that the feeling of saturation is formed, in particular, from the impulse of the receptors of the stomach, which are activated by mechanical stimulation of food entering the stomach. Thus, reducing the size of the stomach, a feeling of satiety is formed more quickly and, as a consequence, the patient consumes less food.
  • combined interventions, combining restrictive and shunt operations.

• Shunt operations

The first printed work on this topic appeared in 1954, when AJ Kremen published his results of an in-line shunt. "Eyuno" in Latin denotes jejunum, and "ileo" - iliac. The word shunt translates as a connection. The first resection of the site of the small intestine was performed by the Swedish surgeon V. Herricsson in 1952. J. Pajn began to switch off the entire small intestine and the right half of the large intestine from the passage of food for rapid and significant weight loss. In this case, the small intestine intersects and creates its connection with the large intestine, while the food does not pass over the entire surface of the small intestine, but only over its small part, and, not absorbed, enters the large intestine. Improving this technique in 1969, J. Payn and L. De Wind proposed an operation of the shunt, which consisted in anastomosing the initial 35 cm of jejunum with the terminal 10 cm of the ileum.

In the 70 years, this operation was most widespread and in connection with a relatively smaller number of complications. Thus, when performing such operations, only 18 cm of the small intestine remains, in which the usual process of digestion remains. To reduce the frequency of postoperative complications, a biliary intubation was developed, or a connection was created between the initial section of the shunt and the gallbladder.

Currently, various modifications of this operation with different length of the ileum are used, which is determined depending on the body weight, sex, age, speed of passage of barium in the intestine.

• Bypass surgery on the stomach

To date, more than 10 major modifications of stomach operations are known. All operations on the stomach change the size and shape of the stomach. The goal is to create a small reservoir in the upper part of the stomach that holds a small amount of food and leads to a slowdown in the evacuation of gastric contents from the small artificially created ventricle to the small intestine or into the stomach. For the first time such operations began to perform E. Mason and D. Jto. JF Alden simplified the operation in 1977, suggesting that the stomach be stitched in hardware without cutting it.

In these two operations, anastomosis (joint) was carried out between the large curvature of the artificially created gastric reservoir and jejunum. However, a common complication was the development of gastritis and esophagitis (inflammation of the stomach and esophagus). To prevent this complication, WO Griffen proposed a gatrogenteroanastomosis for Rou behind the colon. Torress JC in 1983 began to create gatroteroanastomosis between the small curvature of the stomach and the distal department of the small intestine. Thus, a restrictive operation on the stomach was supplemented by a decrease in absorption in the intestine.

With this method as a complication, a decrease in the level of the protein of the blood and as a consequence of edema developed. Salmon PA proposed in 1988 to combine vertical gastroplasty and distal gastroshunting. It should be noted that with gastroshunting, there are fewer serious complications than after ejshnoshunting.

In 1991, a variant of gastroshunting was proposed, known as the Fobi small ventricular formation, with the imposition of a temporary gastrostomy, which, according to the authors, reduces the incidence of mechanical suture inconsistency, the formation of ulcers in the anastomosis area, and avoids weight gain in the postoperative period.

• Plastic operations on the stomach

In addition to a variety of operations that shunt the stomach, there are options for plastic surgery on the stomach (gastroplasty), which can be divided into two groups: horizontal and vertical.

The first horizontal gastroplasty was performed in 1971 by E. Mason. He cut the stomach transversely from the small curvature and formed a narrow channel along the large curvature. The operation was recognized as unsuccessful because the volume of the ventricle was large, and in the postoperative period, it expanded as a result of stretching the walls of the stomach under food pressure. The soybean did not strengthen, which also led to an increase in its diameter. In the postoperative period, patients quickly stopped losing weight.

Later, CA Gomez modified the operation in 1981, suggesting an intraoperative measurement of the volume of the small ventricle and the creation of an 11 mm anastomium along a large curvature, which was strengthened by circular non-absorbable serous-muscular sutures. However, often in the postoperative period these seams became the cause of stenosis, and their further eruption resulted in an increase in anastomosis, an increase in the size of the small ventricle, and restoration of the initial weight.

To prevent the expansion of anastomosis, JH Linner has since 1985 strengthened the outlet from the small ventricle with a silicone circular bandage. E. Mason noted that the walls of small curvature of the stomach have a smaller thickness of the muscular layer and therefore are less prone to stretching. In this regard, he proposed to create a small ventricle along a small curvature, oriented vertically. The essence of the operation is the formation of a small part of the stomach in the subcardial region, which communicates with the rest of the stomach through a narrow opening. To prevent the expansion of the outlet from the small ventricle, it was strengthened with a 5 cm polypropylene tape. This operation was called Vertical Banded Gastroplasty (VBG). This operation has established itself as an operation with fewer systemic complications.

There is another way to form a small ventricle, performed with polypropylene tape, which was started in 1981 by LH Wilkinson and OA Pelosso. In 1982, Kolle and Bo proposed using a fluorovascular vascular prosthesis for this purpose, which is preferable to synthetic tape, since it creates a uniform pressure on the stomach wall and prevents the development of pressure ulcers of the stomach wall or perforation. Soup between the two parts of the stomach is 10 - 15 mm and is formed on the gastric probe. Initially, the horizontal bandage was much worse than vertical gastroplasty in its results. However, after the improvement of this technique in 1985, the bandage has become more widely used in the practice of bariatric surgeons. Hallberg and LI Kuzmak offered adjustable silicone bandages.

The band has a hollow inner part that is connected through a silicone tube to the injection tank in the area of the anterior abdominal wall. Thus, when the liquid of the inner part of the bandage is filled, the diameter of the outlet from the small ventricle decreases, which allows to influence the rate of evacuation of food from their stomach and, as a consequence, the rate of weight loss in the postoperative period. The advantage of this operation is low traumatism, preservation of the natural passage of food through the digestive tract and an insignificant frequency of purulent-septic complications. In addition, the operation is reversible, and if necessary, it is always possible to increase power by increasing the diameter of the cuff.

• Combined Interventions

Separately, it is worthwhile to single out in this group of operative interventions the biliopancreatic shunting proposed by Skopinaro N. In 1976. The essence of the operation consists in resection of 2/3 of the stomach, at the intersection at a distance of 20-25 cm from the ligament of the jejunum of the jejunum, creating an anastomosis between the stump of the stomach and the distal section of the jejunum and in anastomosing the proximal part of the intestine with iliac type "end-in side "at a distance of 50 cm from the ileocecal angle (the place of the confluence of the ileum into the blind). In this case, bile and pancreatic juice are included in the process of digestion only at the level of the ileum.

In recent years, the use of variants of biliopancreatic bypass is often used - "duodenal switch", in which the small intestine is anastomosed not with the stump of the stomach, but with the intersected 12 - duodenal intestine. This avoids the development of peptic gatrointestinal ulcers and reduces the incidence of anemia, osteoporosis, and diarrhea. Biliopancreatic shunting can be combined with longitudinal gastrectomy.

Biliopancreatic bypass can be performed laparoscopically. At this type of operation weight reduction during the 12-year observation is 78% of the excess body weight. The operation does not restrict people in food and can be used for uncontrolled hyperphagia, for example, in the syndrome of Wili-Prader.

• Laparoscopic Horizontal Gastroplasty

The variant of this operation is gastric banding, performed by endovideosurgical access. As a result of the installation of an adjustable silicone cuff, a ventricle with a volume of no more than 25 ml is formed, where there is a restriction of food intake. As mentioned above, it is possible to adjust the diameter of the anastomosis between the two sections of the stomach through an injectable reservoir implanted in the subcutaneous tissue.

At the early stages of the introduction of this operation, the following complications were encountered in practice: the expansion of the small ventricle, the displacement of the gastric band, the stenosis of the anastomosis in the early period as a result of edema. In 1995, M. Belachew modified this technique and suggested the following principles: the initial volume of the small ventricle should not exceed 15 ml, the posterior dissection should be performed above the gland box cavity, where the posterior wall is fixed. This allows you not to apply seams to the back of the stomach. The front wall is completely fixed above the gastric band using 4 joints. To prevent stenosis of the anastomosis as a result of edema and the displacement of the bandage, the latter is installed in the position of its maximum internal diameter.

Intervention is performed from 4 to 5 trocar accesses. The essence of the operation is the creation of a tunnel in the retroastral space above the cavity of the small omentum. The reference point is the lower boundary of a 25 ml balloon, strengthened on the gastric probe and set at the level of the cardiac pulp of the stomach. The duration of the operation is on average 52 - 75 minutes.

[1], [2], [3], [4], [5], [6], [7], [8]