M. PARDELA, M. WIEWIÓRA, T. SITKIEWICZ, M. WYLEZO£
THE PROGRESS IN BARIATRIC SURGERY
Department of General and Bariatric Surgery in Zabrze, Medical University of Silesia, Katowice, Poland
Morbid obesity, caused by fat tissue accumulation, is a serious multi-factorial chronic disease, with rapidly increasing prevalence in most countries in the world including Poland. Conservative treatment of morbid obesity is almost always unsatisfactory and that is why several surgical methods have been developed. There are four kinds of methods: malabsorptive procedures; restrictive procedures; malabsorptive/restrictive procedures and experimental procedures. The development of bariatric surgery goes back to 1952 and since that time it has been evolving dynamically. All the surgical methods have benefits and disadvantages. Presently the introduction of minimally invasive surgical techniques seems to be very safe, efficient and cost-effective in treatment for morbid obesity. New methods are also being evaluated, such as gastric myo-electrical stimulation. Bariatric surgery will still be developing until we understand all the factors responsible for it is origin. K e y w o r d s : morbid obesity, bariatric surgery, malabsorptive and restrictive procedures
INTRODUCTION
Morbid obesity is known as a chronic, multi-factorial disease, usually of a genetic origin, which is caused by excessive accumulation of the tissue. The prevalence of obesity is rapidly increasing in most countries of the world, also in Poland (1, 2). Obesity, as a serious disease, determines not only socioeconomic, but first of all medical consequences. Conservative treatment is almost always unsuccessful in achieving a significant long - term weight loss, especially in morbid obesity with BMI > 40 kg/m2 - even if a body mass reduction is achieved, it is
usually transitory (3). That is why several surgical treatments have been proposed. All of them lead to long-duration of body weight loss (4). These are as follows:
from the caecum. The blind loop was connected to the caecum. In 1956 Payne at al. performed jejunocolic bypass. Unfortunately, the postoperative period was very dramatic so that this kind of method was discontinued (6). All the complications after all those operations were the result of misunderstanding of the physiological bases of intestinal absorption and the role that each part of the digestive tract plays.
MALABSORPTIVE PROCEDURES
In 1969 a new operating technique was developed by PayneDeWind -jejunoileal bypass - 14/4 operation (35 cm jejunumto 10 cm ileum) (7) (Fig. 1). The results were satisfactory, the operative mortality rate was low and acceptable (2,5-6%) and the weight loss was significant. No malabsorptive symptoms and signs were present as were observed after jejunocolic anastomosis procedures. But still 1/3 of patients required part-time hospital observations, supplemental nutritional support and new nutritional behaviours, sometimes even reversal surgery due to water-electrolytes loss or potassium, magnesium and calcium deficiency (8). Sometimes there were many deaths secondary to liver failure after such bypass (9). In 1985, Pardela and Dró¿d¿ proposed original operative technique in which 45 cm jejunum was connected to 15 cm ileum procedure with bilateral subphrenic vagotomy but without pyloroplasty (10). Slow, but constant weight loss was observed in 25% of patients and a relatively low rate of complications was observed in comparison to the 14/4 technique. The high complication rate of jejunoileal bypass during the years led to abandonment of the malabsorption procedures for obesity surgery, and the gastric restriction operations became more frequently used.
RESTRICTIVE PROCEDURES
Vertical-Banded-Gastroplasty (VBG), developed by Mason in 1980, became the most popular operating technique (11). This procedure has been undergone
almost only by laparoscopic approach and has become a "gold standard" in surgical treatment of morbid obesity. The principle of Mason procedure was to decrease the amount of swallowed solid food. The stomach was divided in to two parts: a small pouch at a volume of 25-50 ml that communicated with the remaining part of the stomach through a narrow channel, 12 mm wide (Fig. 2A). Non-absorbable mesh-band at the length of 60 mm was wrapped around the lesser curvature channel. This technique can only be performed with the use of mechanical sutures - staples. Unfortunately, long-term postoperative results were less nsatisfactory. According to Nieghtengal et al.(12), as well as Howardet al. (13), only in 38% of patients weight loss of 50% was gained over 3 years. Another very popular restrictive technique was a gastric banding described in 1983 by Bo and Modalsky (14) and in 1986 by Kuzmak (15). The band was placed in the upper part of the stomach dividing it into two parts: smaller volume of 30 ml, which was connected with the rest of the stomach through the narrow channel (Fig. 2B). At present two types of band are available: an adjustable gastric band (AGB) and non adjustable gastric band. An adjustable gastric band Fig.1. Malabsorptive procedure: jejunoileal bypass - 14/4 operation (35 cm jejunum to 10 cm ileum)
Fig.2. Restrictive operations. This procedure leading to restriction in food intake by dividing the stomach into two parts connected by a narrow channel. (A)Vertical Banded Gastroplasty; (B Gastric banding; C). Adjustable Gastric Banding
A
B
reduction operation with and without distal stomach exclusion (17). The stomach was divided horizontally and gastrojejunostomy was created between the proximal gastric pouch and the proximal jejunum. The gastric pouch was 100-150 ml with a stomach 12 mm diameter. Various modifications have been introduced since then, for example Roux-en-Y gastrojejunostomy (Fig. 3A). It is the most popular operating technique at present: a small stomach pouch is separated and then joined to the small intestine through a tight hole at a diameter of 10 mm. The distal part of the stomach, duodenum and the first 50 cm of jejunumare excluded (18). The alimentary pathway consists of 150 cm of intestine. "Dumping syndrome" may occur in some patients after this type of surgery depending on the level of high-calorie food intake.
Based upon experimental studies, Italian surgeon Nicola Scopinaro described a new operating technique in 1979: biliopancreatic diversion (BPD) (19). The stomach was subtotally resected (80% of distal part), with closure of the duodenal stump, the rest was anastomosed to 250 cm of jejunum - alimentary tract and anastomosis of the proximal part of jejunum- enzymatic tract - to the Roux limb 50 cm proximal to the ileocaecal valve (20) (Fig. 4A). The new common limb was then created. In most patients after this type of surgery diarrhea was reported with four to six fatty-type stools daily. Also protein disorders and vitamin (especially D) deficiencies are observed in the postoperative time.
Accordingly other variations of operating techniques were introduced, one of which is duodenal switch with distal bypass introduced by Hess in 1998 (21). This operation is due to the vertical gastrectomy and preserves the pylorus by excising the greater curvature of the stomach (Fig. 4B). The duodenumis divided above the Vater papilla with closure of the distal stump. The proximal part below the pylorusis anastomosed to enteric limb 250 cm from the Treitz ligament. The end of the jejunum is then anastomosed to ileum 75-100 cm proximal to the ileocaecal valve. The new common digestive limb created that way decreases significantly metabolic disturbances and pylorus prevents the "dumping syndrome". This kind of operation was used widely in Canada and the west coast of the USA.
§stomal dilatation (nonbanded gastroplasties) §stomal stenosis
§prosthetic erosion of stoma (banded gastroplasty) §staple line dehiscences
§dilatation of proximal pouch §maladaptive eating behavior §persistent vomitings §gastroesophageal reflux
"Dumping syndrome" is a side effect and occurs in more than 70% of patients after gastric bypass operation. The Fobi operation causes very quick body mass reduction of approx. 75% by decreasing caloric intake, and no increase of body mass was observed in 5 years. In 90% of patients the postoperative results were reasonably good.
In 2004 Gidon Almogy at al. described a new operating technique which consisted of longitudinal subtotal gastrectomy - longitudinal gastrectomy (75% of stomach was resected) (24). The authors state that this is a very safe and effective method especially in high risk patients and can be used preliminary to duodenal switch (DS).
The introduction of laparoscopy decreased significantly the perioperative number of deaths as the well as number of complications in terms of wound
Fig.3.Malabsorptive/restrictive procedure. (A) Roux-en-Y gastric bypass (B) Very, very long-limb Roux-en-Y gastric bypass; (C) Silastic ring vertical Roux-en-Y gastric bypass - Fobi pouch.
infections, bowel obstruction, respiratory and circulatory insufficiency. It also shortens the mean hospital stay and reduces total hospitalization costs.
EXPERIMENTAL PROCEDURES
A new procedure, gastric myo-electrical stimulation, is being evaluated to treat morbid obesity. Cigaina proposed electrostimulation of the stomach as therapy for morbid obesity (25).
BARIATRIC SURGERY IN POLAND
Interest in bariatric surgery in Poland appeared in 1970s. In 1972 the first surgical procedures - jejunoileal bypass - were performed in Gdañsk and Poznañ (Krygier, Góral) and in 1974 the same operation was developed by Go³¹b in Zabrze (26) (Fig. 5A).
Fig.4. Malabsorptive/restrictive bariatric procedures. (A) Biliopancreatic diversion; (B) Duodenal switch.
During the years 1993-2003, 917 procedures have been carried out. Among them 78.5% are commonly done restrictive ones, than VBG-75%, LSAGB - 15% and SRVG-8% and at last NAGB with 2% (29). Less popular are the malabsorptive procedures with BPD 3.8% and RYBG - 17.7%. Since 1998 the laparoscopic procedures have been performed, on regular basis only in one centre. During the last three years relatively high number of 455 bariatric procedures has been performed. Since 2001 the Polish Association for Prevention and Treatment of Obesity became a member of IFSO. There are 13 surgeons interested and trained in bariatric surgery who are the members of this Association. The number of morbidly obese patients treated in Poland is increasing every year, but is inadequate to the growing demand. We feel that our further cooperation with IFSO will positively affect better understanding of this kind of treatment in Poland among physicians and patients.
How long will bariatric surgery be developing? Up to the day when we understand all the factors responsible for its origin.
Fig.5.Pionieers of the bariatric surgery in Poland. (A) Prof. Roman Góral; (B) Prof. Marian Pardela.
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Authors address: Prof. M. Pardela, M.D. Department of General and Bariatric Surgery Zabrze, Medical University of Silesia, Katowice, ul. Sk³odowskiej-Curie 10, 41-800 Zabrze, Poland. Tel./fax: +48 (32) 271 63 36.
