OBES SURG (2008) 18:121–128
DOI 10.1007/s11695-007-9308-7
REVIEW
Bariatric Surgery: The Past, Present, and Future
Alan A. Saber & Mohamed H. Elgamal &
Michael K. McLeod
Received: 23 September 2007 / Accepted: 8 October 2007 / Published online: 8 December 2007
# Springer Science + Business Media B.V. 2007
Abstract
Background Our objective is to review the history and
development of different procedures of bariatric surgery,
along with a summary of the most commonly performed
bariatric procedures today and a look on the future trends in
the field of bariatric surgery.
Methods Review of the available English language litera-
ture concerning bariatric surgery.
Results The literature review included articles that have
information about the history of bariatric surgery, different
techniques used for each procedure, and the outcome of
each procedure.
Conclusions Bariatric surgery is a dynamic field. Experts
are continuously searching for an ideal, minimally invasive
procedure that is both safe and effective.
Keywords Bariatric . History . Future
Introduction
In the United States, the overall prevalence of obesity has
increased geometrically from 12.8% in 1962 to 30.5% in
2000 [1]. This explains the increased number of bariatric
procedures performed in the USA annually from about
16,000 in 1990 [2] to about 140,000 in 2005 [3].
The rationale of this communication is to highlight the
evolution of bariatric surgery over the last several decades.
A. A. Saber (*) : M. H. Elgamal : M. K. McLeod
Section of Minimally Invasive Surgery and Bariatric Surgery,
Michigan State University/Kalamazoo Center for Medical Studies,
1000 Oakland Dr., Kalamazoo, MI 49008, USA
e-mail: saber@kcms.msu.edu
This review will emphasize the lessons learned from the
past; highlight the present practice of bariatric surgery, and
offer predictions regarding what may be ahead over the
next decade in this dynamic field.
The Concept of Bariatric Surgery
The concept for a surgical treatment of obesity was
developed from observing the significant postoperative
weight loss developed in patients that had large portions
of their stomachs or small intestines removed [4]. This
inspired the development of different schools of thought
in bariatric surgery that can be categorized into three
approaches including malabsorptive, restrictive, and com-
bined malabsorptive-restrictive procedures.
Purely Malabsorptive Procedures
The Jejunoileostomy
In 1953, Varco of the University of Minnesota performed
the first surgery developed specifically to induce weight loss
[5]. It was an end-to-end jejunoileostomy with a separate
ileocecostomy for drainage of the bypassed segment.
Payne et al. in 1963 [6] described a series of jejunocolic
bypass procedures in which they made an end-to-side anas-
tomosis between the proximal jejunum to the midtransverse
colon. This resulted in a dramatic weight loss; however, the
associated electrolyte imbalances, uncontrolled diarrhea, and
liver failure mandated reversal of the procedure.
In 1965, Sherman [7] modified this procedure to a
jejunoileostomy that utilized an end-to-side anastomosis
between the proximal jejunum and the distal ileum. This was
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subsequently modified to an end-to-side jejunoileostomy
utilizing 14 in. of jejunum and 4 in. of ileum (the so-called
14+4 procedure), which became the standard malabsorptive
procedure (Fig. 1). However, 10% of the patients did
not experience satisfactory weight loss because of the reflux
of nutrients back into the ileum. This experience encour-
aged Scott et al. [8] and Buchwald et al. [9] in 1971 to
return to the original end-to-end jejunoileostomy with the
jejunal stump drained into the transverse colon to prevent
intussusception [10].
The jejunoileostomy led to significant weight loss.
Unfortunately, this procedure was associated with many
malabsorption complications that eventually led to the
abandonment of the jejunoileostomy and provided the
impetus for the development, refinement, and eventual
adoption of the gastric bypass procedure [11].
The Biliopancreatic Diversion
To overcome the complications of the previous procedures,
a new generation of procedures was developed. This new
generation shared the principle of not depriving any part of
the gut from intestinal flow.
In 1979, Scopinaro [12] introduced a new generation of
malabsorptive procedure referred to as the biliopancreatic
diversion. This procedure involved partial gastrectomy with
closure of the duodenal stump. Then the jejunum was
divided 250 cm proximal to the ileocecal valve. Subse-
quently, the distal part of the jejunum (the Roux limb) was
anastomosed to the stomach, and the proximal part of the
jejunum (which drains the biliopancreatic secretions) was
anastomosed to the ileum 50 cm proximal to the ileocecal
valve. The latter step created a short common intestinal
channel.
This procedure resulted in weight loss by decreasing
the time that digestive enzymes could interact with food,
decreasing the absorptive surface available for nutrient
absorption, and accelerating the transit time for food to pass
out of the stomach. The procedure had a minor restrictive
Fig. 1 Malabsorptive procedures
OBES SURG (2008) 18:121–128
component depending on the size of the stomach left in
place [13].
The biliopancreatic diversion proved to be very effective.
In 1998, Scopinaro et al., reported 21 years of experience
with 2441 patients who underwent this procedure. The initial
weight loss was reported to be 75% of excess weight after
1 year, and this weight loss was maintained throughout the
author’s period of follow-up [14]. This procedure allowed
the patients to eat more while maintaining their weight loss.
The main complications observed for the biliopancreatic
diversion were diarrhea, flatulence, anemia, stomal ulcers,
bone demineralization, protein malabsorption, dumping
syndrome, and anastomotic leak [15].
Combined Malabsorptive and Restrictive Procedures
These procedures combining malabsorptive and restrictive
components depend on both decreasing the stomach size
and decreasing nutrient absorption, to promote weight loss.
Such procedures include duodenal switch, gastric bypass,
and digestive adaptation (Fig. 2).
The Duodenal Switch
In 1986, Hess modified the biliopancreatic diversion by
anastomosing the Roux limb to the first portion of the duo-
denum, thus preserving the pyloric sphincter. This modi-
fication eliminated stomal ulcers and dumping syndrome
[16]. In addition, Hess added a restrictive component by
dividing the stomach vertically to create a narrow tube
along the lesser curve of the stomach.
The duodenal switch has resulted in the highest recorded
rate of weight loss [17]. The follow-up of 440 cases demon-
strated an initial excess weight loss of 80% at 18 months
postoperatively. This positive weight loss then persisted for
at least 8 years [18].
Patients undergoing this procedure remained at risk for
developing malnutrition, diarrhea, and vitamin deficiencies.
OBES SURG (2008) 18:121–128
Fig. 2 Combined malabsorptive/restrictive procedures
Therefore, these patients required long-term follow-up,
nutritional supplementation, and careful ongoing monitor-
ing of their nutritional status [19].
The Gastric Bypass
Gastric bypass was developed based on observing the
excessive weight loss experienced by patients who under-
went gastrectomy with a Billroth II gastrojejunostomy. The
observed weight loss was theorized to be caused by the
patient’s decreased gastric capacity for meals, decreased
acid production with resultant decreased digestion, and the
early passage of food into the small intestine (dumping
syndrome) [20].
In 1966, Mason and Ito performed the first gastric
bypass procedure for weight loss. Their procedure consisted
of dividing the stomach horizontally and connecting a loop
gastrojejunostomy to the proximal gastric pouch [21].
Initially, the gastric pouch size was not measured. Alder
and Terry [22] subsequently published in 1977 a study that
correlated the size of the pouch with the long-term weight
loss observed. These authors argued that according to
LaPlace’s Law, the larger the pouch the more the tension
on the wall leading to more dilatation. Based on their
experience, they concluded that an adequate size for the
gastric pouch was less than 30 cc.
123
In the same year, Alden [23] proposed stapling the
stomach instead of dividing it to decrease the incidence of
gastric leak. However, the frequent failure of the staple line
with the subsequent restoration of the continuity of the
stomach forced the return to the practice of dividing the
stomach.
In 1977, Griffen and colleagues [24] introduced the
Roux-en-Y configuration to the gastric bypass procedure to
replace the loop gastrojejunostomy. This modification
eliminated bile reflux into the stomach, decreased the ten-
sion on the jejunal loop, and added a malabsorptive compo-
nent to the procedure. In 1983, Torres et al. [25] described
the use of a long Roux limb as a way of increasing the
degree of malabsorption to enhance the weight loss.
In 1988, Salmon [26] modified the gastric bypass proce-
dure by adding a vertical-banded gastroplasty to prevent
dilatation of the pouch outlet. In 1989, Fobi used a silastic
ring to maintain the gastric restriction. Further, he inter-
posed the jejunal limb of the Roux-en-Y between the
gastric pouch and the distal stomach to try to decrease the
development of gastro-gastric fistula [27].
In 1993, Wittgrove and Clark performed the first
laparoscopic Roux-en-Y gastric bypass with EEA stapled
gastrojejunostomy [28]. They reported on a 6-year experi-
ence with 500 patients who experienced initial excess
weight losses of 80%. Later in 1999, Higa et al. described a
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hand-sewn laparoscopic gastrojejunostomy technique to use
instead of the stapler to decrease the incidence of an
anastomotic leak [29].
Currently, the Roux-en-Y gastric bypass is the most
common bariatric procedure performed in the United States.
Approximately 140,000 Roux-en-Y gastric procedures were
performed in 2005 [30]. The weight loss documented from
this procedure has proven to be durable and reproducible.
Digestive Adaptation
In 2002, Santoro et al. developed a new bariatric proce-
dure that they called digestive adaptation. This procedure
consists of a sleeve gastrectomy and an enterectomy that
retains the first 50 to 100 cm of jejunum and the last 200
to 250 cm of ileum [31]. The aim of this procedure is to
induce a combined restriction and controlled malabsorption
without altering normal gastrointestinal physiology. In
2006, their preliminary reports indicated a loss of 80%
of excess body weight in patients followed for 12 months
postoperatively [32].
Restrictive Procedures
Such procedures (Fig. 3) aim to decrease the size of the
stomach, which leads to the consumption of smaller meals
and, consequently, loss of weight. As such, the weight loss
Fig. 3 Restrictive procedures
OBES SURG (2008) 18:121–128
occurs without altering the normal physiologic passage of
food, and thus eliminates the malabsorptive side effects.
Gastroplasty
In 1971, Mason and Printen performed the first horizontal
gastroplasty. In this procedure, the stomach is horizontally
divided into a small upper pouch and a lower pouch con-
nected by a small channel along the greater curvature of
the stomach [33]. However, the weight loss that resulted
from this procedure was unsatisfactory and believed to be
secondary to the dilatation of the channel. In 1977, Gomez
reinforced the channel with a Dacron mesh collar, but this
resulted in excessive fibrosis and gastric obstruction. Later,
he replaced the Dacron mesh with a running polypropylene
suture. Unfortunately, this latter maneuver was complicated
by suture erosion into the stomach [34]. In 1979, Pace et al.
[35] tried to create a stoma midway between the greater and
lesser curvatures of the stomach.
In 1978, Long used an oblique staple line from a stoma
(supported by a Prolene suture) in the fundus to the lesser
curvature. This was based on the idea that the lesser cur-
vature has thicker muscle, and thus, would be more resis-
tant to dilatation [36]. In the same year, Laws used a silastic
ring instead of a polypropylene suture to avoid the compli-
cation of suture erosion [37]. This was followed in 1980 by
the Waynne-Jones modification that utilized a hand-sewn
vertical gastroplasty [38].
OBES SURG (2008) 18:121–128
In 1980, Mason described vertical banded gastroplasty.
In this procedure, he used a lesser curvature stoma sup-
ported by a Marlex band passed through a window created
by a circular stapler. This procedure became the gold stan-
dard for vertical banded gastroplasty for approximately
a decade [39]. In 1993, Chua and Mendiola performed
the first successful laparoscopic gastroplasty [40]. In 1996,
Champion introduced the laparoscopic vertical banded
gastroplasty with wedge resection of gastric fundus [41].
As no anastomosis is created during a gastroplasty, the risk
of leak and subsequent peritonitis is low. Nutritional compli-
cations are not significant because there is no malabsorptive
component in this procedure [42]. However, approximately
5% of patients develop a stomal stricture [43].
Gastric Banding
Gastric banding was developed to be the least invasive
bariatric procedure. It does not include any transection or
stapling of the stomach. In this procedure, a band is
wrapped around the stomach creating a small upper pouch
connected through a narrow channel to the distal stomach.
In 1976, Tretbar et al. conducted the first trial using this
approach. He used a fundoplication procedure that involved
wrapping the fundus around the stomach to decrease the
size of the stomach [44]. In 1980, Wilkinson and Molina
separately performed the first gastric banding procedures
using Marlex mesh and Dacron vascular graft material,
respectively [45].
In 1986, Kuzmak introduced the first adjustable gastric
band utilizing an inflatable silastic band connected to a
subcutaneous port that could be used to control the size of
the band by adding or withdrawing saline [46]. In 1993,
Catona et al. performed the first laparoscopic nonadjustable
gastric banding procedure [47]. In the same year, Belachew
and his colleagues performed the first laparoscopic adjust-
able gastric banding procedure [48]. In 1999, Cadiere per-
formed the first robotic gastric banding, which was also the
first robotic bariatric procedure of any kind [49].
In 2001, The FDA approved the LAP-BAND® for use
in the United States [50]. Gastric banding has the advantage
of reversibility and adjustability with no required injury to
the stomach wall. However, band slippage, obstruction, and
erosion of the band are recognized complications. In addi-
tion, the observed weight loss resulting from successful
gastric banding has been less than that observed from other
bariatric procedures [51].
Sleeve Gastrectomy
This procedure involves a laparoscopic vertical gastrectomy
that excises the fundus and the lateral 80% of the gastric
125
body leaving a small, sleeve-like stomach with an intact
pylorus. Marceau et al. originally described this procedure
in 1993 as the restrictive component of the biliopancreatic
diversion with duodenal switch procedure [52].
Sleeve gastrectomy can be employed as a first stage
preceding either duodenal switch or gastric bypass; it can
also be used as a definitive procedure in some patients [53].
In 2006, Silecchia et al. reported their experience using
the sleeve gastrectomy as the first stage in a multistage
procedure in super obese patients with at least two severe
comorbidities. Two years after sleeve gastrectomy, more
than 50% of their patients demonstrated resolution of their
comorbidities [54].
Gastric Pacing
In 1994, Cigaina proposed the idea of inserting electrodes
in the stomach wall to induce a sensation of fullness and
thereby decrease food intake [55]. These electrodes are
connected to a battery placed in the rectus sheath and con-
trolled by a remote control device. He performed the first
procedure in humans in 1995.
This minimally invasive procedure does not involve any
transection or alteration of the stomach or any part of the
gastrointestinal tract. The initial excess weight loss achieved
is 20% in 1 year and 25% in 2 years [56].
Minimally Invasive Bariatric Approach
Today, every bariatric surgical procedure can be performed
laparoscopically. Although 65% of bariatric procedures
were performed laparoscopically in 2003, it is known that
this percentage is growing [57]. Morbid obesity was once a
contraindication to laparoscopy, but the lower rates of com-
plications observed when compared to that of open surgery
have made morbid obesity an indication for laparoscopy
[58]. The laparoscopic approach is as effective as open sur-
gery. However, laparoscopy has the advantages of smaller
incisions, less wound complications, faster recovery, and
earlier ambulation with less respiratory compromise.
Staged Procedures
A less invasive procedure including gastric sleeve, adjust-
able gastric banding, or placement of an intragastric bal-
loon can be used to achieve a degree of weight loss that
will improve the general condition of the patient and
permit a more effective bariatric procedure, such as the
Roux-en-Y gastric bypass or duodenal switch procedure,
to be performed later. This approach is helpful in super
126
obese patients or in patients with severe comorbidities that
limit their ability to tolerate operative stress and general
anesthesia.
Many authors have studied this concept. In 2005, Milone
et al. concluded that laparoscopic sleeve gastrectomy was
superior to endoscopic intragastric balloon as a first stage
procedure in the super obese patient [59]. In 2006, Cottom
et al. studied the use of sleeve gastrectomy as a first-stage
weight loss procedure before proceeding to a laparoscopic
Roux-en-Y gastric bypass [60].
The Future
Bariatric surgery continues to evolve, and there are many
advances anticipated to come. The increasing magnitude of
the problem of obesity and the significant increase in the
number of bariatric procedures performed each year will
provide many opportunities for further research. Innovation
and improvement will enhance bariatric surgery’s role in
promoting health in our patients. Many new procedures and
techniques are appearing on the horizon, and some of these
approaches will be discussed briefly.
Robotic Surgery
Minimally invasive techniques are becoming the “gold
standard” approach, and robotic surgery has the potential to
advance the use and development of minimally invasive
procedures. It helps bariatric surgeons to increase their pre-
cision and will help improve the outcome of many complex
procedures. Robotic surgery proved to be faster and easier
to perform than the standard laparoscopic procedure while
being more ergonomic and less stressful on the surgeon [61].
In 2003, Muhlmann et al. conducted a study comparing
laparoscopic vs. robotic bariatric procedures. The robotic-
aided procedure proved to be 30% faster than were even
experienced laparoscopic surgeons [61]. Primary and
revision robotic-assisted bariatric procedures can be made
technically simpler with the benefit of the precise instru-
ment handling afforded by the use of robotic assistance.
However, robotic-assisted procedures remain very expen-
sive, and the setup of the system is time consuming.
Endoluminal Bariatric Surgery
Significant morbidities are still associated with the current
available bariatric procedures; therefore, the search for
alternative, safer surgical modalities to promote weight loss
continues. Surgeons are exploring the use of endoluminal
surgery, also known as “natural orifice” surgery. This novel
OBES SURG (2008) 18:121–128
approach includes endoluminal devices placed inside the
stomach or intestine, which could be used to achieve weight
loss. The main advantage of this type of surgery is the
elimination of the need to perform surgical incisions with
their subsequent associated complications. Several ideas are
currently under study.
Restrictive Endoluminal Procedures
In 2001, Evans and Scott proposed the use of an endoscopi-
cally inserted intragastric balloon (IGB) for the treatment of
morbid obesity, particularly in preparation for a more defini-
tive bariatric procedure [62]. In 2005, Genco et al. reported
an extensive experience with the intragastric balloon in
2,515 patients. After 6 months, excess weight loss was
33.9% with resolution or improvement of comorbidities in
90% of their patients [63].
In 2004, Felsher et al. described an experimental study
using the endolaparoscopic placement of an intragastric
circular prosthesis with a central aperture. This resulted in a
30- to 50-ml proximal gastric reservoir. Long-term studies
are necessary to demonstrate the efficacy and long-term
weight loss achieved using this approach, or with the use of
an alternate intraluminal gastric partitioning technique [64].
Malabsorptive Endoluminal Procedures
In 2006, Milone et al. proposed the use of a polyethylene
endoluminal duodeno-jejunal tube (EDJT). This tube is open
from both ends and allows the passage of food without it
mixing with biliary and/or pancreatic juices. The intent of
this approach was to decrease the absorption of nutrients
resulting in weight loss. This was demonstrated first in a
porcine model [65]. A trend to reduced weight gain was
obtained with the use of a longer tube.
As the need for bariatric surgery grows, more surgeons
will get involved in performing bariatric procedures. As a
result, there will be more training and research opportuni-
ties available. Particular attention continues to be given to
the operative details and perioperative care to decrease
complications and increase the safety of bariatric proce-
dures. The ultimate goal remains to develop a procedure
that is both safe and effective. To date, no available phar-
macotherapy has proved to be effective and well tolerated
for patients wishing to lose their weight [66].
However, the basic fund of knowledge of the physio-
logical and pathological aspects of obesity continues to
grow with time. Both surgeons and pharmaceutical compa-
nies are continuously searching for the ideal treatment
modality that will help millions of obese patients through-
out the world.
OBES SURG (2008) 18:121–128
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