Surgeons in various locations in Europe and America began performing jejuno-ileal bypass surgery on obese patients in the 1950s. Then in the 1960s, jejuno-colic bypass surgery was performed, but unacceptable side effects of frequent diarrhea, dehydration, and electrolyte imbalance, resulted in discontinuance of the procedure. Late in the 1960s, Dr Edward Mason of the University of Iowa developed the Roux-en-Y gastric bypass procedure, and in the early 1980s Dr Mason pioneered the vertical banded gastroplasty procedure . Today the gastric bypass and variations of the vertical banded gastroplasty are used in the majority of bariatric operations. A less commonly used and more surgically complicated procedure is the biliopancreatic diversion (BPD).
Bariatric surgeries are categorized as either restrictive or restrictive malabsorptive operations. A restrictive bariatric operation reduces the size of the stomach, which restricts the amount of food consumed at one time. It does not cause malabsorption of nutrients. A restrictive malabsorptive operation incorporates both a reduction in the size of the stomach and a surgical bypass of certain parts of the small intestine involved in absorption of some nutrients. The vertical banded gastroplasty (VBG) is an example of a restrictive operation. The procedure involves creating a vertical partition with staples starting at the top of the stomach. This creates a 30ml gastric pouch along the lesser curvature of the stomach. The outlet diameter is 10 to 12 mm and is supported on the outside with a Marlex mesh or a Gore-Tex strip so the inner diameter does not expand when a large volume of food is consumed. In order to place the band below the vertical line, the front and back walls of the stomach are stapled together in a circular fashion with gastric tissue removed to create a window so the band can be placed through the stomach and below the staple line. This keeps the band in a stable position (Figure 7.1). The procedure is performed either through a traditional abdominal incision or by laparoscopy . The VBG does not result in anemia or micronutrient deficiencies because all food that enters the stomach is passed
through the digestive system. Because the stomach size is surgically reduced, patients experience satiety with less food, which results in weight loss.
Another restrictive approach commonly promoted through the Internet is the laparoscopic adjustable silicone gastric banding, known as the LAP-BAND® . After the vertical partitioning of the stomach is completed, a hollow silicone band is placed around the lesser curvature and the distal end of the partitioned part of the stomach. Inflation of the band occurs when saline is passed through an access port under the skin. This controls the size of the gastric outlet opening (Figure 7.2) .
The Roux-en-Y gastric bypass is the most common restrictive malabsorptive gastric bypass procedure performed for treatment of obesity . This operation creates a 10 to 30 ml gastric pouch in the proximal portion of the stomach. The gastric pouch is created by surgically resecting or stapling across the gastric fundus or along the lesser curvature of the stomach to create the pouch. The result is to make a gastrojejunostomy with the distal end of the jejunum anastomosed 50 to 150ml below the gastrojejunostomy, thus creating a Y-shaped jejunum (Figure 7.3).
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