*Hady Razak Hady1, Magdalena Luba1, Mikolaj Czerniawski1, Paweł Wojciak1, Inna Diemieszczyk1, Patrycja Pawluszewicz1, Agnieszka Swidnicka-Siergiejko2, Regina Sierzantowicz3, Marta Jastrzebska-Mierzynska4, Monika Jedynak5, Paulina Wozniewska1, Jerzy Robert Ladny1, 6
Progress in bariatric-metabolic surgery
Postępy w chirurgii bariatryczno-metabolicznej
1Ist Department of General and Endocrine Surgery, University Clinical Hospital in Bialystok, Poland
2Department of Gastroenterology and Internal Medicine, University Clinical Hospital in Bialystok, Poland
3Department of Health Sciences, Medical University of Bialystok, Poland
4Department of Dietetics and Clinical Nutrition, Medical University in Bialystok, Poland
5Department of Anesthesiology and Intensive Care, Medical University in Bialystok, Poland
6Department of Emergency and Disaster Medicine, Medical University of Bialystok, Poland
W związku epidemią otyłości na świecie, w tym w Europie oraz Polsce, chirurgia bariatryczno-metaboliczna stała się jedną z głównych dyscyplin zabiegowych na przełomie XX i XXI wieku.
Początki rozwoju chirurgii bariatrycznej miały miejsce w USA oraz krajach Europy Zachodniej w latach 50. XX wieku. W latach 80. i 90. dziedzina ta szybko rozpowszechniła się na całym świecie. Obecnie rocznie na świecie wykonuje się ok. 500 000 różnorodnych operacji bariatryczno-metabolicznych, w tym ponad 2000 zabiegów w 15 ośrodkach bariatrycznych w Polsce.
Zabiegi bariatryczno-metaboliczne są najskuteczniejszą metodą leczenia otyłości i chorób jej towarzyszących, w tym najgroźniejszych chorób zespołu metabolicznego, takich jak: cukrzyca typu 2, nadciśnienie tętnicze i uogólniona miażdżyca.
Bariatric-metabolic surgery has become one of the main surgical disciplines at the turn of the 20th and 21st century in connection with the obesity epidemic in the world, Europe and in Poland.
The beginning of the development of bariatric surgery in the 1950s occurred in the USA and Western Europe, and then rapidly spread throughout the world in the 1980s and 1990s. Currently, about 500,000 various bariatric and metabolic operations are performed, including more than 2,000 procedures in 15 bariatric centers in Poland.
Currently, bariatric and metabolic procedures are the most effective methods of treating obesity and co-morbidities, including the most dangerous diseases of the metabolic syndrome, type 2 diabetes and generalized atherosclerosis.
Bariatric surgery worldwide and in Poland
Bariatric-metabolic surgery in connection with world epidemic of obesity, its proven efficiency in treatment of this lesion and technological progress in the field of laparoscopy is recently one of the most developing field of surgery. Pursuant to the report of IFSO (International Federation for the Surgery of Obesity and Metabolic Diseases) presented in 2015, the number of bariatric procedures performed in 2013 exceed 460 000 cases worldwide including 154 000 procedures performed in the USA and Canada. Laparoscopic technique is a basis for surgical treatment of obesity, 95.7% of procedures has been performed using this technique, while in 2013 the most frequently applied method was gastric bypass (45%), further, sleeve gastrectomy (37%) and gastric banding (10%). However, there are some differences in application of those procedures depending on the region of the world. In case of USA, Canada, Asia and region of Pacific Ocean, the most common procedure is SG, which is on the second position in Europe and South America after gastric bypass. It is worth mentioning that within last 10 years (2003-2013), since its first performance, sleeve gastrectomy is gaining popularity to the detriment of gastric banding (1).
It is estimated that currently in Poland, 2000 procedures is performed within the field of bariatric surgery in 15 bariatric centers, mainly using 3 recommended methods: sleeve gastrectomy, gastric bypass (with the modification – mini gastric bypass) and gastric banding. The number is highly insufficient regarding 400 000 patients with morbid obesity.
The history of bariatric methods development
The beginning of bariatric surgery development is set in 1950s in connection with the observation of significant body mass loss in patients after gastrectomy or intestinal resection in treatment process of peptic ulcer disease or cancers, and adaptation of those procedures for the purposes of obtaining body mass reduction in obese patients. Proposed, at the time, restrictive procedures – initially jejuno-ileo bypass described by Kremen et al., procedures of anastomosis of small intestine with the transverse colon performed by Payne, de Wind and Scott caused significant body mass loss, however, according to superficially induced short intestine syndrome they led to unacceptable insufficiencies in vitamins absorption, deterioration of fats digestion or other complications which caused resignation from those methods (2-4).
In this period, the tendency was to apply more restrictive methods limiting the volume of the stomach which would not cause the disorders of absorption and their complications. Initially, horizontal sewing of the stomach has been applied (so called Pacey’s and Carrey’s gastroplasty) but in face of the lack of long term effects in 1967 Mason and Ito proposed total horizontal cutting of the stomach connected with the anastomosis with intestinal loop which started the idea of one of the main contemporary methods joining the exclusion of the part of gastrointestinal tract and gastrointestinal restrictive-malabsorption (gastric bypass) (5). The technique of this procedure has been significantly modified by Griffen et al., who in 1977 introduced Roux-Y-en gastric bypass which prevent bile retrograde (6). The technique of modern gastric bypass underwent numerous modifications mainly in the part of length of nutritional and enzymatic loop and in laparoscopy it has been performed for the first time in 1993 by Wittgrove and Clark.
1980s brought innovative approach to bariatric surgery. In 1979 Scopinaro et al. proposed the procedure of biliopancreatic bypass performed until now, however, due to numerous postoperative complications and difficulties in performance of this type of procedure, very rarely (7). Aforementioned procedure has been further modified in 1993 by Marceau et al. and Hess and Hess by introducing the resection of the stomach in the area of greater curvature and replacement of gastro-ileal anastomosis with duodeno-ileal anastomosis calling the method biliopancreatic diversion duodenal switch (BPD-DS) which is performed until today (8, 9). In further years, active work on restrictive methods development have been conducted: in 1978 the method of unadjustable gastric banding has been introduced and further replaced in 1986 with adjustable gastric banding. In 1980, Maison, who has been considered as a pioneer of restrictive methods in bariatric surgery, performed, for the first time, horizontal gastroplasty in which he joined horizontal resection of upper part of the stomach with implementation of polypropylene ring (10-12).
The idea of finding the method which could be efficient and simultaneously changing the physiology of gastrointestinal tract as little as possible found its reflection in “Magenstrasse and Mill” method proposed by Johnston in 1987 remaining modern sleeve gastrectomy with one difference: in the area of pylorus the opening has been performed using round stapler and the resection begun in this place along to the His’s angle. LSG in modern form has been described for the first time in 1988 as a part of the procedure BPD-Ds. As an isolated procedure in open technique, it has been performed in 1993 and laparoscopically in 2000 by Ganger, and since then it gained popularity so it is respectively new method of surgical treatment of obesity (13).
In Poland, the pioneer of bariatric surgery is undoubtedly Pardela et al. who in the early 70’s made the first gastrointestinal exclusion for the treatment of obesity and from 1993 in the center in Zabrze, he also performed vertical gastric banding (14, 15). The first laparoscopic surgery to treat obesity in Poland also Has been performed in Zabrze in 1998 and included the insertion of a gastric band (16). For the first time gastric bypass surgery was performed in 1999 in classical technique and a year later laparoscopically. Sleeve gastrectomy performed from the beginning by laparoscopic technique was performed in Poland for the first time in 2003.
The first methods of bariatric surgery applied in Podlasie was Roux-y gastric bypass with the classical technique and laparoscopic adjustable gastric banding performed in the 1st Department of General and Endocrinological Surgery, Medical University of Bialystok in May 2005 by Hady Razak Hady. Laparoscopic sleeve gastrectomy was performed for the first time in 2008 (17, 18).
Classification of bariatric-metabolic surgery methods
Since the beginning of bariatric surgery, the classification of surgical methods of obesity treatment has been based on the mechanism of action that currently in connection with intensive research on the effects of individual treatments, the increasing knowledge of the pathomechanism of obesity itself and innovative ideas of the treatments itself is more complicated than it was initially thought. According to the classification proposed earlier, bariatric surgery May be divided into: restrictive, malabsorptive and mixed. Currently, this division is considered obsolete and not practical, but useful for training purposes. Very often, a separate group is innovative experimental treatments. The choice of the proper type of surgery is an individual decision of the surgeon and the patient due to the fact that the European Association for Endoscopic Surgery (EAES) so far has only developed guidelines that should be followed in the selection in the absence of a clear indication for a method identified as the appropriate one.
Rely on reducing the volume of the stomach without altering the physiology of the gastrointestinal tract
A. VGB – Vertical banded gastroplasty
Procedure for a long time considered the “golden standard” of bariatric treatment. Originally, the technique involved the creation of a “hole” in the two stomach walls with a diameter of 2.5 cm at a distance of about 5 cm from the Hiss angle and then from the “opening” to the top of the stitching calibrated on the 32F probe of the stomach with linear staplers. The treatment ended with the placement of a polypropylene mesh band (Marlex) around the narrowed part of the stomach. The most common complication was the creation of a channel connecting both parts of the stomach separated by the stapler and weight regaining (fig. 1, 2).
Fig. 1. Mason technique VBG (source: www.mp.pl)
Fig. 2. MacLean technique VBG (source: www.mp.pl)
MacLean in 1993 introduced a modification to prevent this phenomenon in which, Rusing a cutting linear stapler, he led to a complete vertical separation of the digestive reservoir from the bottom of the stomach. The treatment in both techniques was also performed laparoscopically (LVBG) which significantly reduced the number of complications and mortality as well as improved the effectiveness of the procedure. % EWL in literature data after 1 year from LVBG ranged from 50 to 56.9% and after 4 years from 50.3 to 61% (19-21). This operation is currently very rarely performer, as suggested by the authors of the 10-year observation of the effects of this procedure – wrongly (22).
B. AGB – Adjustable gastric banding
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