History of the development of bariatric surgery

Bariatric surgery is a method of operative (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 types of various surgical interventions were proposed to treat obesity. Today, there are 4 main methods of surgical treatment:

• • operations aimed at reducing the area of the intestinal absorption surface (bypass operations - jejunoileal bypass). The intestine is the place where nutrients entering the human body are absorbed. When the length of the intestine through which food passes is reduced, the effective functional surface of the intestine is reduced, i.e. the absorption of nutrients is reduced and fewer of them enter the blood.
  • operations aimed at reducing the absorption surface of the stomach - gastric bypass. The mechanism of this operation is the same. Only the stomach, not the intestine, is excluded from the absorption process. In this case, the shape of the stomach changes.
  • operations aimed at significantly reducing the volume of the stomach - gastrorestrictive. During these operations, the size of the stomach is changed, which leads to a decrease in its volume. It is known that the feeling of satiety is formed, among other things, from the impulses of the stomach receptors, which are activated by mechanical irritation of food entering the stomach. Thus, by reducing the size of the stomach, the feeling of satiety is formed faster and, as a result, the patient consumes less food.
  • combined interventions that combine restrictive and bypass operations.

• Bypass operations

The first printed work on this topic appeared in 1954, when AJ Kremen published his results of jejunoileal shunting. "Jejuno" in Latin means the jejunum, and "ileo" means the ileum. The word shunt is translated as a connection. The first resection of a section of the small intestine was performed by the Swedish surgeon V. Herricsson in 1952. J. Pajn began to exclude almost 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 is crossed and a connection is created with the large intestine, while food does not pass along the entire surface of the small intestine, but only along a small part of it, and, without being absorbed, enters the large intestine. Improving this technique in 1969, J. Payn and L. De Wind proposed a jejunal bypass operation, which consisted of anastomosing the initial 35 cm of the jejunum with the final 10 cm of the ileum.

In the 70s, this operation became most widespread due to the relatively lower number of complications. Thus, when performing such operations, only 18 cm of the small intestine remains, in which the normal digestion process is preserved. To reduce the frequency of postoperative complications, biliary bypass was developed, or the creation of a connection between the initial section of the bypassed intestine and the gallbladder.

Currently, various modifications of this operation are used with different lengths of the ileum, which is determined depending on body weight, gender, age, and the rate of passage of barium through the intestine.

• Gastric bypass surgery

To date, more than 10 main modifications of stomach operations are known. All stomach operations change the size and shape of the stomach. The goal is to create a small reservoir in the upper part of the stomach, which holds a small amount of food and leads to a slowdown in the evacuation of gastric contents from a small artificially created stomach into the small intestine or into the stomach. Such operations were first performed by E. Mason and D. Jto. JF Alden in 1977 simplified the operation by proposing to suture the stomach using hardware without cutting it.

In these two operations, an anastomosis (connection) was performed between the greater curvature of the artificially created gastric reservoir and the 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 Roux-en-Y gastroenteroanastomosis behind the colon. Torress JC in 1983 began to create a gastroenteroanastomosis between the lesser curvature of the stomach and the distal part of the small intestine. Thus, restrictive surgery on the stomach was supplemented by a decrease in absorption in the intestine.

With this method, a decrease in the blood protein level and, as a consequence, edema developed as a complication. Salmon PA proposed in 1988 to combine vertical gastroplasty and distal gastric bypass. It should be noted that gastric bypass has fewer serious complications than jejunal bypass.

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

• Plastic surgery on the stomach

In addition to various gastric bypass surgeries, 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 lesser curvature and formed a narrow channel along the greater curvature. The operation was considered unsuccessful because the volume of the created stomach was large, and in the postoperative period it expanded as a result of stretching the walls of the stomach under the pressure of food. The ostium was not strengthened, 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, proposing intraoperative measurement of the small ventricle volume and creation of an 11-mm anastomosis along the greater curvature, which was reinforced with circular non-absorbable serous-muscular sutures. However, these sutures often caused stenosis in the postoperative period, and their further cutting led to an enlargement of the anastomosis, an increase in the size of the small ventricle and restoration of the original weight.

To prevent the dilation of the anastomosis, J. H. Linner began to strengthen the outlet from the small ventricle with a silicone circular bandage in 1985. E. Mason noted that the walls of the lesser curvature of the stomach have a smaller thickness of the muscle layer and are therefore less susceptible to stretching. In this regard, he proposed creating a small ventricle along the lesser curvature, oriented vertically. The essence of the operation is to form 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 dilation of the outlet from the small ventricle, it began to be strengthened with a 5 cm long polypropylene tape. This operation was called Vertical Banded Gastroplasty (VBG). This operation has proven itself as an operation with fewer systemic complications.

There is another method of forming a small stomach, performed with the help of a polypropylene tape, which was started to be performed in 1981 by LH Wilkinson and OA Pelosso. In 1982, Kolle and Bo suggested using a fluorolavsan vascular prosthesis for this purpose, which is preferable to a synthetic tape, since it creates uniform pressure on the stomach wall and prevents the development of pressure ulcers of the stomach wall or perforation. The opening between the two sections of the stomach is 10-15 mm and is formed on a gastric tube. Initially, horizontal banding was significantly worse in its results than vertical gastroplasty. However, after improving this technique in 1985, banding was more widely used in the practice of bariatric surgeons. Hallberg and LI Kuzmak proposed adjustable silicone bands.

The bandage has a hollow inner part, which is connected to the injection reservoir in the anterior abdominal wall via a silicone tube. Thus, when the inner part of the bandage is filled with liquid, the diameter of the outlet from the small stomach decreases, which allows influencing the rate of evacuation of food from the stomach and, as a result, the rate of weight loss in the postoperative period. The advantage of this operation is low trauma, preservation of the natural passage of food through the digestive tract and a low incidence of purulent-septic complications. In addition, the operation is reversible, and if necessary, it is always possible to increase nutrition by increasing the diameter of the cuff.

• Combined interventions

It is advisable to separately highlight in this group of surgical interventions biliopancreatic bypass, proposed by Skopinaro N. in 1976. The essence of the operation is the resection of 2/3 of the stomach, the intersection of the jejunum at a distance of 20-25 cm from the Treitz ligament, the creation of an anastomosis between the stump of the stomach and the distal section of the transected jejunum and the anastomosis of the proximal section of the transected intestine with the ileum according to the "end-to-side" type at a distance of 50 cm from the ileocecal angle (the place where the ileum enters the cecum). In this case, bile and pancreatic juice are included in the digestion process only at the level of the ileum.

In recent years, biliopancreatic bypass variants have been frequently used - "duodenal switch" ("switching off the duodenum"), in which the small intestine is anastomosed not with the gastric stump, but with the transected duodenum. This allows avoiding the development of peptic gastrointestinal ulcers and reducing the incidence of anemia, osteoporosis, and diarrhea. Biliopancreatic bypass can be combined with longitudinal resection of the stomach.

Biliopancreatic diversion can be performed laparoscopically. With this type of surgery, weight loss during a 12-year follow-up is 78% of excess body weight. The surgery does not restrict people in food and can be used for uncontrolled hyperphagia, for example, in Willy-Prader syndrome.

• Laparoscopic horizontal gastroplasty

A variant of this operation is gastric banding, performed by endovideosurgical access. As a result of installing an adjustable silicone cuff, a ventricle of no more than 25 ml is formed, where food intake is limited. As mentioned above, it is possible to regulate the diameter of the anastomosis between the two sections of the stomach through an injection reservoir implanted in the subcutaneous tissue.

In the early stages of introducing this operation into practice, the following complications were encountered: dilation of the small ventricle, displacement of the gastric band, stenosis of the anastomosis in the early period as a result of edema. In 1995, M. Belachew modified this technique and proposed the following principles: the initial volume of the small ventricle should not exceed 15 ml, the posterior dissection should be performed above the cavity of the omental bursa, where the posterior wall is fixed. This allows not to apply sutures to the posterior wall of the stomach. The anterior wall is completely fixed above the gastric band using 4 sutures. To prevent stenosis of the anastomosis as a result of edema and displacement of the band, the latter is installed in the position of its maximum internal diameter.

The intervention is performed from 4-5 trocar accesses. The essence of the operation is to create a tunnel in the retrogastric space above the cavity of the lesser omentum. The reference point is the lower border of a 25 ml balloon fixed to a gastric tube and installed at the level of the cardiac sphincter of the stomach. The duration of the operation is on average 52-75 minutes.

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