SPECIAL ARTICLE Overview of the of and the Early History of Procedures to Remedy Morbid Obesity

Kenneth G. MacDonald, Jr, MD

besity may be defined by weight, (BMI) (calculated by dividing weight in kilograms by height in meters squared), and percentage of body fat, although no categorization is universally accepted. The cause is multifactorial, with genetic, en- O vironmental, socioeconomic, and behavioral or psychological influences. Health conditions caused or exacerbated by , while obesity is defined as a BMI obesity include , mel- of 30 or more. A BMI of 35 or more with litus (DM), and obesity hy- serious comorbidity, or a BMI of 40 or more, poventilation, back and joint problems, car- is considered morbid obesity. Other defi- diovascular disease, pseudotumor cerebri, nitions of morbid obesity include more than thromboembolic disease, and others. Ma- 45.2 kg (Ͼ100 lb) over the ideal body lignancies occur with increased incidence weight as defined by the 1983 Metropoli- in persons who are obese and include breast, tan Life Insurance Height and Weight tables endometrial, and colonic neoplasms. Nu- or a body weight exceeding 200% of the merous recent studies, increasingly re- ideal body weight. ported in the lay press, emphasize the in- While most obese people are over- creasing incidence of obesity in the United weight, not all overweight individuals are States, with concomitant increases in the re- obese. Included in this latter group would lated morbidity and mortality. An esti- be very muscular athletes, such as weight- mated 64.5% of American adults (Ͼ120 mil- lifters or football players, who do not have lion people) are overweight or obese, an excess body fat. Methods of calculating increase from 45% in 1960.1 The inci- body fat include underwater weighing, mea- dence of juvenile obesity has doubled in the suring total body water using isotopic di- last 20 years, affecting an estimated 15% of lution, measuring total body potassium children between 6 and 19 years old.2 Obe- level, bioelectrical impedance analysis, and sity is widely recognized as one of the pri- measurements using computed tomogra- mary national health issues and has been phy or magnetic resonance imaging. These predicted to soon surpass smoking as the techniques are not widely used in assess- leading cause of preventable mortality in the ment of obesity owing to expense, techni- United States. Health care costs associated cal difficulty, and lack of sufficient valida- with obesity are incalculable. Costs for DM tion.4 Circumference and skinfold thickness alone are estimated at $100 billion annu- measurements are more practical because ally. The incidence of DM has increased par- of simplicity; however, these measure- allel with that of obesity, from 9 million ments are more useful to determine re- adult cases in 1991 to 15 million in 2001.3 gional fat distribution rather than total body fat. Waist circumference as an indicator of DEFINITION OF OBESITY excess abdominal or visceral fat has been associated with dyslipidemia, hyperten- Obesity is strictly defined as an excessive ac- sion, and glucose intolerance.5 cumulation of body fat. The BMI has be- come the most commonly accepted mea- PREVALENCE surement. A BMI exceeding 25 is considered While estimates may vary between stud- From the Department of Surgery, Division of Gastrointestinal Surgery and Surgical ies, there is general agreement that the Endoscopy, The Brody School of Medicine at East Carolina University, Greenville, NC. prevalence of obesity has increased steadily

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©2003 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/29/2021 over the last 2 to 3 decades in the United States and world- bined inheritance of obesity and DM, and even DM as a wide. The National Center for Health Statistics in 1999 cause of obesity.16 reported that 61% of adults in the United States were over- Improvement in glucose tolerance with weight (BMI Ն25) and that 26% were obese (BMI Ն30). following gastric bypass for morbid obesity has been well Prevalence rates differ with sex, age, race or ethnicity, documented in our series at East Carolina University, Green- and socioeconomic status. American women have a higher ville, NC. In a cohort of 608 morbidly obese patients,17 27% prevalence of obesity than men. African American and had DM type 2 and another 27% had impaired glucose tol- Mexican American women and men have higher rates of erance (IGT), which is a known risk factor for subsequent obesity than white women and men (Third National development of type 2 DM, as well as an independent risk Health and Nutrition Examination Survey [NHANES III], factor for .18 On long-term fol- 1988-1994).6 While the prevalence of obesity tends to low-up after Roux-en-Y gastric bypass, 82.9% of the pa- be lower in less well-developed countries, it is higher in tients with DM maintained normal levels of plasma glu- lower socioeconomic and less educated groups in the cose, glycosylated hemoglobin, and insulin. During an United States.7 average follow-up of 7.6 years after Roux-en-Y gastric by- Of great concern is the increased US prevalence of pass, 98.7% of the IGT group remained euglycemic, while childhood and adolescent obesity. Rates of obesity among 1.2% developed type 2 DM. In a previous comparison of children aged 6 to 11 years increased from 4% in the Na- the surgical IGT group with a control group of nonoper- tional Health Examination Survey for 1963-1965 to 13% ated on obese patients with IGT, there was a greater than in 1999 (NHANES-IV). There was a similar increase in 30-fold decrease in risk of developing type 2 DM in the pa- adolescents aged 12 through 19 years from 5% for 1966- tients in the surgical IGT group.19 Analysis of those pa- 1970 to 14% in 1999.8 As in adults, prevalence rates are tients in both the DM and IGT groups who did not remain highest for Hispanic and Native American children of both euglycemic revealed that 37% had inadequate weight loss sexes and for African American females. Genetic, socio- owing to failure of the surgery. The remaining nonre- economic, environmental, and dietary influences are all sponders were an average of 7.3 years older and had had implicated. The incidence of type 2 DM in adolescents their DM diagnosed for 3 years longer than the euglyce- has increased in proportion to the increase in obesity, with mic patients. The observation that the probability of re- an average BMI of 38 in patients who have newly diag- version to normal glucose metabolism with weight loss de- nosed DM in this age group.9,10 creases with age and duration of DM suggests that there is a deterioration of islet cell function over time. HEALTH EFFECTS OR COMORBIDITIES In a retrospective comparison of an obese cohort with DM who underwent Roux-en-Y gastric bypass with a The hallmark study by Drenick et al11 in 1980 clearly dem- matched group of obese control subjects with DM who onstrated excess mortality in a group of 200 morbidly did not undergo surgery for nonmedical reasons, the in- obese males followed up for a mean of 71⁄2 years. During cidence of death in the control group was 4.5 times that the course of the study, 25% of the group died. There of the surgical patients.20 Of the control group, 28% died was a 12-fold excess mortality compared with the gen- during 6.2 years of follow-up, while only 9% of the sur- eral population in the 25- to 34-year-old group and 6-fold gical group died during a longer 9-year follow-up, in- excess mortality in the 35- to 44-year-old group. Car- cluding perioperative deaths. The largest reduction was diovascular disease was the most common cause of death, in cardiovascular mortality, representing 54.5% of the con- while injuries (trauma, eg, motor vehicle, falls, indus- trol deaths vs only 14.3% of the surgical group deaths. trial injuries, and others) were surprisingly frequent. Over- weight (Ͼ110% of the ideal body weight) nonsmoking Hypertension men in the Framingham study had 30-year mortality rates as high as 3.9 times that of normal-weight men.12 Many population-based studies have documented the as- sociation of obesity with hypertension. The NHANES data Diabetes Mellitus showed that the prevalence of hypertension in over- weight adults was 2.9 times that of normal-weight adults.21 The association of obesity and type 2 DM is well known. This correlation was more pronounced in younger age The increase in prevalence of obesity over the last de- groups. There is a clear relationship among hyperten- cade has been accompanied by a 25% increase in preva- sion, insulin resistance, and hyperinsulinemia.22 Effects lence of DM,13 which increases dramatically with a BMI on tubular sodium resorption and on the renin- exceeding 25.14 Diabetes mellitus is a major cause of angiotensin-aldosterone system have been suggested as stroke, blindness, renal failure, lower extremity ampu- possible mechanisms. Hyperinsulinemia has further been tations, and ischemic cardiac disease. The mortality rate associated with hyperlipidemias and atherogenesis, termed from cardiovascular disease is substantially higher for pa- “syndrome X.”23 tients with DM than without DM.15 There is an increased risk of DM in many groups EARLY SURGICAL TREATMENT OF OBESITY that also have an increased prevalence of obesity, such as African Americans, Hispanics, Native Americans, and Jejunoileal Bypass those of low socioeconomic status. There is evidence to support independent inheritance of DM and obesity, in- The history of surgery for morbid obesity began in 1954, creased genetic susceptibility for DM with obesity, a com- when Kremen et al24 published the first case report of an

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©2003 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/29/2021 end-to-end jejunoileostomy performed for weight reduc- cluded intestinal segment was associated with various prob- tion. Payne then initiated the first clinical program of in- lems, including intussusception, bypass enteritis, and co- testinal bypass for morbid obesity in 1956, initially per- lonic pseudo-obstruction. Hocking et al30 reported that the forming an end-to-side anastomosis of the proximal 15 cm risk of progressive liver disease existed indefinitely and that of jejunum to the midtransverse colon. In 1963 Payne25 re- ongoing careful follow-up was necessary. Griffen et al fi- ported initial results in 11 patient revealing dramatic weight nally stated, “...a50%morbidity rate and roughly a 10% loss, although at the expense of significant morbidity with mortality following jejunoileal bypass are sufficient rea- severe diarrhea, electrolyte imbalance, and hepatic fail- sons to abandon it as an appropriate operation for the mor- ure, leading to 1 death. While Payne originally postulated bidly obese.”31(p307) a second operation to increase bowel length would be re- quired after achieving ideal weight, the jejunocolic shunt Modern Malabsorptive Procedures was widely condemned26 and, ultimately, abandoned. In an attempt to achieve a more physiologically tol- Descendant operations of the JIB persist in the form of the erable operation, intestinal bypass with restoration of con- biliopancreatic diversion, first reported in 1979,32 and the tinuity proximal to the ileocecal valve was proposed. Payne duodenal switch. These modern operations differ from the and DeWind27 performed an end-to-side jejunoileostomy, JIB variants in that no intestinal limb is excluded from flow anastomosing the proximal 36 cm (14 in) of jejunum to of some type, thus, eliminating the blind loop syndromes the terminal ileum 10 cm (4 in) proximal to the ileocecal or bacterial overgrowth that were likely contributing causes valve. The distal divided end of the jejunum was left as a of the liver problems, arthralgias, bypass enteritis, and co- blind end. Their experience with this “14+4” procedure lonic pseudo-obstruction seen with JIB. The biliopancre- with 58 patients was reported in 1969.27 As with many of atic diversion, as described by Scopinaro in MacDonald the earlier reports on bariatric procedures, important data, et al,33 is constructed with a 200- to 500-mL proximal gas- such as mean percentage of excess body weight lost at vari- tric pouch, a distal gastrectomy to reduce incidence of mar- ous intervals after surgery, percentage of follow-up, and ginal ulcer, and a nonrestrictive gastroileostomy per- lengths of follow-up, were not discussed. formed 250 cm proximal to the ileocecal valve. The Numerous variations of the jejunoileal bypass (JIB) biliopancreatic limb is anastomosed to the intestinal limb were subsequently introduced. While preservation of the 50 cm proximal to the ileocecal valve. Fat absorption, there- ileocecal valve did reduce problems with unmanageable di- fore, is restricted to the short 50-cm common channel, arrhea, there was variable reflux of intestinal contents with while protein and starch are absorbed throughout the the end-to-side anastomosis into the bypassed segment of 250-cm intestinal limb. Scopinaro and colleagues32,33 re- bowel, leading to unpredictable weight loss. In response ported 73% to 78% loss of excess body weight from 2 to to this problem, Scott et al28 performed an end-to-end je- 14 years after surgery, with a protein rate of junoileostomy with drainage of the bypassed intestine into only 2.7%. Close follow-up and patient compliance are nec- either the sigmoid or transverse colon. In their report of essary to minimize this complication. 200 patients in 1977,28 they compared Payne’s 14+4 op- Duodenal switch is a variant of the biliopancreatic eration with 3 variations of the end-to-end procedure that diversion with original modifications by Marceau et al34 differed in the length of distal ileum (15 vs 20 vs 30 cm [6 in 1993 and Hess and Hess35 in 1998. The primary dif- vs 8 vs 12 in]) anastomosed to 30 cm (12 in) of proximal ferences of the switch include a greater curve gastrec- jejunum. Weight loss with these procedures cannot be com- tomy and preservation of the pylorus, with anastomosis pared directly with later procedures, as results were re- of the enteric limb to the first portion of the duodenum ported as a change in ratio of to weight, or just distal to the pylorus. As with the biliopancreatic di- by the undefined terms “satisfactory,” “not ideal,” and “un- version, the biliopancreatic secretions are diverted to the satisfactory.” The groups with 30 cm of distal ileum who distal common channel. Reported benefits include re- underwent the Payne operation lost less weight and most duced marginal ulceration, reduced protein malnutri- began to regain weight after 2 or more postoperative years. tion, and reduced hepatic dysfunction. The groups with 15 and 20 cm of distal ileum had greater sustained weight loss, with more than 70% losing “to the Gastric Restrictive Procedures range of ideal weight.” Persistent diarrhea was a problem with these 2 groups in 20% to 45% of the patients. Mason and Ito36 first described the gastric bypass in 1967, With increasing experience and length of follow-up, beginning the era of gastric restrictive procedures. Griffen a growing variety of complications related to JIB were re- et al37 noted similar weight loss to that seen with JIB with ported. Of 230 patients who underwent the 14+4 end-to- fewer late complications. Because of technical difficulties side procedure, DeWind and Payne29 reported that 29 (49%) associated with gastric bypass and concern about the ex- of the men and 88 (51%) of the women required rehospi- cluded distal stomach, many varieties of gastroplasties were talization for management of complications related to the introduced during the 1970s by Gomez,38 Pace et al,39 and operation. Percentage of initial weight lost in 2 years was LaFave and Alden.40 The basic design of these proce- from 32% to 54%. Overall, mortality was 8%, including 10 dures was a stapled partitioning of the proximal stomach deaths due to liver failure. There were significant prob- to create a small pouch that communicated with the dis- lems with hypoalbuminemia, hypokalemia, hypocalce- tal stomach through a restrictive channel. These proce- mia, hyperbilirubinemia, migratory polyarthralgias, cal- dures were widely performed because of their technical cium oxalate urinary calculi, and elevated liver enzymes simplicity and lack of metabolic complications. Over time, levels. Diarrhea and flatulence were common. The ex- however, excessive failure rates were noted, at least par-

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©2003 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/29/2021 tially due to pouch and outlet dilation. Conversely, ex- 6. Kuczmarski RJ, Flegal KM, Campbell SM, Johnson CL. Increasing prevalence of overweight among US adults:The National Health and Nutrition Examination Sur- cessive restriction often led to reflux problems and the mal- veys, 1960 to 1991. JAMA. 1994;272:205-211. adaptive eating behavior of liquids and soft foods, resulting 7. DiGirolamo M, Harp J, Stevens J. Obesity: definition and epidemiology. In: Lock- in . Comparative studies by Pories et al,41 Lin- wood DH, Heffner TG, eds. Obesity: Pathology and Therapy. New York, NY: 42 43 Springer-Verlag; 2000:3-28. ner, and Naslund et al confirmed the superior results 8. Crawford PB, Story M, Wang MC, Ritchie LD, Sabry ZI. Ethnic issues in the epi- of gastric bypass over those of the gastroplasties. demiology of . Pediatr Clin North Am. 2001;48:855-878. 9. 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Pories WJ, Swanson MS, MacDonald KG, et al. Who would have thought it? an As medical approaches to weight loss have been gen- operation proves to be the most effective therapy for adult-onset diabetes mel- erally inadequate and unsuccessful, surgery has emerged litus. Ann Surg. 1995;222:339-352. 18. Harris MI. Diabetes in America: epidemiology and scope of the problem. Diabe- as the primary treatment for morbid obesity. Early surgi- tes Care. 1998;21(suppl 3):C11-C14. cal procedures, the JIBs, involved bypass of variable lengths 19. Long SD, O’Brien K, MacDonald KG Jr, et al. Weight loss in severely obese sub- jects prevents the progression of impaired glucose tolerance to type II diabetes: of small intestine to create malabsorption. Owing to an un- a longitudinal intervention study. Diabetes Care. 1994;17:372-375. acceptable incidence of complications with JIB proce- 20. MacDonald KG Jr, Long BS, Swanson MS, et al. 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Intestinal bypass surgery for morbid obesity: long-term patient follow-up, and lack of standardization of the tech- results. JAMA. 1976;236:2298-2301. 30. Hocking MP, Duerson MC, O’Leary P, Woodward ER. Jejunoileal bypass for mor- nical aspects of the procedures and of reporting of results. bid obesity: late follow-up in 100 cases. N Engl J Med. 1983;308:995-999. 17. With the increasing prevalence of morbid obesity and con- 31. Griffen WO Jr, Bivins BA, Bell RM. The decline and fall of the jejunoileal bypass. comitant increase in procedures and number of surgeons Surg Gynecol Obstet. 1983;157:301-308. 32. Scopinaro N, Gianetta E, Civalleri D, Bonalumi U, Bachi V. Bilio-pancreatic by- performing them, these deficiencies will likely assume in- pass for obesity, II: initial experience in man. Br J Surg. 1979;66:618-620. creasing importance. 33. MacDonald KG Jr, Schauer PR, Brolin RE, Scopinaro N, O’Brien P, Doherty C. : a review. Gen Surg News. 2002;29:19-26. 34. Marceau P, Biron S, Bourque RA, Potvin M, Hould FS, Simard S. Biliopancreatic Accepted for publication December 17, 2002. diversion with a new type of gastrectomy. Obes Surg. 1993;3:29-35. Corresponding author: Kenneth G. MacDonald, Jr, MD, 35. Hess DS, Hess DW. Biliopancreatic diversion with a duodenal switch. Obes Surg. 1998;8:267-282. Department of Surgery, Division of Gastrointestinal Sur- 36. Mason EE, Ito C. Gastric bypass in obesity. Surg Clin North Am. 1967;47:1345- gery and Surgical Endoscopy, The Brody School of Medi- 1351. cine at East Carolina University, TA 245, 600 Moye Blvd, 37. Griffen WO Jr, Young VL, Stevenson CC. A prospective comparison of gastric and jejunoileal bypass procedures for morbid obesity. Ann Surg. 1977;186:500-509. Greenville, NC 27834-4354 (e-mail: macdonaldk@mail 38. Gomez CA. Gastroplasty in the surgical treatment of morbid obesity. AmJClin .ecu.edu). Nutr. 1980;33(suppl 2):406-415. 39. Pace WG, Martin EW Jr, Tetirick T, Fabri PJ, Carey LC. 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