Bariatric surgery--where do we go from here?

Jejuno-ileal bypass (JIB) was introduced in the 1950s. Roux-en-Y gastric bypass (RYGBP) was introduced in the 1960s and gastroplasty (GP) in the 1970s, and then we returned to RYGBP in the 1980s, because GP was noted to have a relatively poor record with long-term maintained weight loss. Also in the 1980s, biliopancreatic diversion (BPD; the Scopinara procedure) was introduced, along with the modification biliopancreatic diversion-duodenal switch (BPD-DS), which came along a few years later in the late 1980s and 1990s. Also in the 1990s, laparoscopy began to flourish, the adjustable gastric band came on the scene, and it soon became apparent that RYGBP and BPD-DS could also be done in this fashion. What to do? This is a study of a series of over 2400 primary RYGBPs done by a single surgeon from 1986 to March 2003, which was preceded by a 7-year experience with various type gastroplasty procedures. Major complications requiring re-operations were less than 2%, and the mortality rate was 0.3%. Mean excess weight loss at 10 years averaged 62%, which compares well with other studies. There are many operative choices in bariatric surgery, which allows us to individualize each patient's needs. However, open RYGBP seems to be a reasonable, if not the best, compromise for the vast majority of patients considering relative risks, benefits, and favorable outcomes. The pros and cons of each approach and the reason for this surgeon's conclusions will be discussed.