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The Development of the Surgical Treatment of Morbid Obesity

Executive Director, International Federation for the Surgery of Obesity, Toronto, CANADA (M.D.)
Associate Professor of Surgery, Tufts University Medical School, Surgical Director of Obesity Consult Center, New England Medical Center, Boston, MA (S.A.S.)

View larger version (35K): [in a new window]   Fig. 1. Jejuno-ileal bypass. A. End-to-end, with the bypassed small bowel anastomosed to colon. B. End-to-side, with the proximal jejunum anastomosed to the distal ileum. The malabsorption results in weight loss. The appendix is removed in all JI bypasses.

View larger version (40K): [in a new window]   Fig. 2. Gastric bypasses, with tiny proximal gastric pouch restricting intake and jejunal loop providing some malabsorption. A. Loop gastric bypass of Mason. B. Roux-en-Y configuration, with stomach partitioned by staple-lines. C. Roux-en-Y configuration, with divided stomach. D. Distal Roux-en-Y gastric bypass: stapled gastric pouch with Roux-limb anastomosed to the lesser curvature (Torres [29]); the shaded area represents Roux (alimentary) limb and common (major digestive) limb.

View larger version (17K): [in a new window]   Fig. 3. Horizontal gastroplasties with small proximal gastric pouches. A. Central staples removed, and stapled partition constructed (Carey [33]). B. Stapled partition, with staples on greater curvature removed (arrow heads) and outlet reinforced by a circumferential suture (Gomez [34]).

View larger version (19K): [in a new window]   Fig. 4.  Vertical banded gastroplasty. A. "Window" enables introduction of a stapler for partition. Mesh band prevents enlargement of outlet [35]. B. Special stapler permits partition without a "window". Silastic ring prevents enlargement of the outlet [36].

View larger version (36K): [in a new window]   Fig. 5.  Biliopancreatic diversion (Scopinaro [40]). A distal gastrectomy is performed. Small bowel is divided 250 cm proximal to ileocecal valve, and is anastomosed to the stomach remnant. The biliopancreatic limb (BPL) is anastomosed to the side of the distal limb 50 cm proximal to the ileocecal valve, to form a 200-cm alimentary limb (AL) and a 50-cm common limb (CL) where the major digestion occurs. The proximal gastric pouch initially restricts intake, which is maintained by the reduced absorptive area. Cholecystectomy is done to prevent gallstones from bile stasis and rapid weight loss.

View larger version (33K): [in a new window]   Fig. 6.  BPD with duodenal switch. The greater curvature portion of stomach is resected to provide initial gastric reservoir reduction. Ileum is divided, and the alimentary limb (AL) is anastomosed to the divided proximal duodenum. The biliopancreatic limb (BPL) is anastomosed to the side of the AL 75–100 cm proximal to the ileocecal valve, forming the distal common limb (CL) [41, 42].

View larger version (20K): [in a new window]   Fig. 7.  Adjustable gastric band. A reservoir under the skin communicates with hollow band, and injection or withdrawal of saline can tighten or loosen the band.