Although complex minimally invasive operations are commonplace today, the story of bariatric and metabolic surgery began as experimental surgery in the mid-twentieth century. In 1952, a Swedish surgeon by the name of Dr. Viktor Henrikson of Göteborg, Sweden, theorized that removal of a generous segment of the small intestine would lead to weight loss and improvement in overall health [1]. He based this theory upon learning of “favorable side effects” reported in patients undergoing small and large bowel resections for other disease processes. Henrikson selected, as his first patient, an obese 32-year-old female with complaints of constipation who had failed to lose weight despite following a strict weight loss program. He resected 105 cm of the small bowel to surgically assist in her weight loss and to improve her overall health and gastrointestinal function. Although this patient ultimately gained 2 kg over a 14-month period postoperatively, she subjectively reported better health, improved energy, and improved bowel function. This first bariatric surgical procedure led Henrikson to recommend further exploration of the potential benefits of bowel resection in obese patients via animal experimentation.

Around the same period of time, anecdotal clinical reports of humans surviving extensive small bowel resections were being reported in the literature. One such report by Dr. Herbert Meyer of New York described the outcome of a World War II veteran who lost the majority of his small bowel from acute mesenteric thrombosis during the Battle of the Bulge and went on to live a relatively normal life [2]. In 1954, Drs. Kremen and Linner of the University of Minnesota published an eloquent study evaluating the nutritional importance of the small intestine in canines [3]. They concluded that sacrificing a significant amount of distal small bowel interferes with fat absorption and results in weight loss. This finding led them to proceed with the first documented human jejuno-intestinal bypass performed in 1954 at the Mount Sinai Hospital in Minneapolis, Minnesota. The interest in such surgical intervention for obesity continued to grow, and in 1963, Payne and colleagues of the University of Southern California reported the results of 10 patients undergoing various types of intestinal bypass operations including jejunoileal (JIB) and jejunocolic shunts with end-to-side anastamoses (see Fig. 1) [4]. This represented the very first publication of a case series of patients undergoing gastrointestinal surgery, specifically with the intent of treating morbid obesity.

Multiple other variations on the jejunoileal and jejunocolic bypass followed. Each attempted to alleviate the complications of the preceding operations and determine the optimal amount of bowel to bypass. Dr. William Scott and colleagues at the Vanderbilt University Medical Center attempted an end-to-end anastomosis instead of an end-to-side anastomosis and varied the length of bypassed bowel showing improved weight loss in patients with more extensive bypass procedures, but worsened side effects [5].

The JIB became the most commonly utilized procedure for weight loss in the 1960s and 1970s. Although weight loss was commonly achieved and appealing, these procedures did not come without complications. As the popularity of the procedure increased, series of patients were studied, and the undesirable side effects became more evident. Malabsorption not only caused weight loss but also led to multiple nutritional deficiencies [6] and anaerobic bacterial overgrowth in the long blind loop of the small bowel [7]. This led to abdominal distention and absorption of bacterial products into the bloodstream resulting in distal manifestations. Patients often presented with a broad spectrum of complications including severe diarrhea, protein malnutrition, vitamin deficiencies, electrolyte imbalance, perianal irritation, polyarthralgias, calcium oxalate stones, nephropathy, and severe liver disease [7–9]. This often required surgeons to reverse such procedures and led to the eventual abandonment of the JIB procedure by the early 1980s [8, 10].

In an attempt to lessen the unfavorable side effects encountered with JIB, Mason and Ito at the University of Iowa developed the gastric bypass procedure. Dr. Edward Mason, commonly referred to as the father of bariatric surgery, worked within the department of surgery at the University of Iowa and met Dr. Chikashi Ito in September of 1965 in Edmonton, Canada, while attending a gastric physiology course. Dr. Robert Tidrick, chief of surgery at the University of Iowa, later hired Dr. Ito as a research collaborator. Mason and Ito ultimately collaborated on developing and studying a gastric bypass procedure based upon the Billroth II procedure which Mason had grown familiar with at the University of Minnesota under his mentor Dr. Owen H. Wangensteen. The main modification was that, unlike the antrectomy in the Billroth II reconstruction used by Wangensteen for peptic ulcer disease, the newer technique left the gastric antrum in place (see Fig. 2) [11].

Following animal experimentation in dogs, Mason and Ito performed the first gastric bypass procedure on May 10, 1966, on a 50-year-old woman with a BMI of 43 kg/m², whose morbid obesity was believed to play a major role in the failure of numerous ventral hernia repairs. This was the first report of a restrictive component to a bariatric operation [11].

While Mason and Ito’s bypass procedure offered attractive results without the complications related to bacterial overgrowth, problems inherent to the Billroth II reconstruction affected patients postoperatively [11, 12]. These included bile reflux and afferent limb syndrome. In the 1970s, Dr. Ward Griffen modified the drainage of the stomach from a short loop retrocolic gastrojejunostomy to a Roux-en-Y configuration [13]. Following Griffen’s landmark publication in 1977, the Roux-en-Y configuration became the preferred method of reconstruction. The procedure continued to gain acceptance as the outcomes were compared to other obesity operations and superior results were noted. In 1987, Sugerman and colleagues reported that gastric bypass had significantly increased weight loss over VBG, and its apparent superiority led to cessation of randomization after only 9 months [14].

In a similar attempt to improve upon the detrimental effects of JIB, Scopinaro and colleagues from Genoa, Italy, introduced the idea of biliopancreatic diversion to allow for selective malabsorption without a blind loop of the small intestine. In 1979, after an experimental study on canines showed several advantages over JIB [15], they reported a series of 18 patients status post biliopancreatic diversion followed up to more than 1 year [16]. This procedure consisted of a hemigastrectomy with closure of the duodenal stump and a Roux-en-Y gastrojejunostomy. The jejunum was divided 20 cm distal to the ligament of Treitz resulting in a biliopancreatic limb which was anastomosed to the distal ileum leaving just 50 cm of common channel. The remaining 200 cm of the small bowel was brought up as a Roux limb to drain the stomach. Scopinaro’s group reported excellent results in weight loss without the negative hepatic side effects observed with JIB, as well as biopsy-proven improvement in liver pathology. Longitudinal studies at 18 and 21 years showed excellent permanent weight loss results, although the authors warned about potential dangers if the operation was not performed as intended [17]. This radical malabsorptive procedure was complicated by anemia, bone demineralization, protein malabsorption, and marginal stomal ulceration [18, 19]. To this day, however, this procedure remains one of the most effective for long-term weight loss results.

In an effort to decrease the complications associated with Scopinaro’s procedure, particularly the marginal ulceration observed with hemigastrectomy and gastrojejunal anastomosis, Dr. Douglas Hess devised and performed the first biliopancreatic diversion with duodenal switch procedure in Bowling Green, Ohio, on March 22, 1988 (Fig. 3) [20]. This operation consisted of creation of a gastric pouch along the lesser curvature of the stomach without disrupting the continuity of the pylorus to the duodenum and a Roux-en-Y duodenojejunostomy. The long tubular pouch in the shape of a sleeve led to the designation of the name “sleeve gastrectomy.” His idea for creating a tubular gastrectomy as the gastric pouch instead of performing a hemigastrectomy was adapted from the duodenal switch procedure for anti-reflux described by DeMeester [21]. Studies showed that the addition of the duodenal switch improved marginal ulceration and dumping syndrome [21]. Despite these improvements, and the excellent weight loss results, this procedure still had its own set of drawbacks leading to reoperations and revisions [22].

Due to the significant complications encountered with malabsorptive procedures, numerous attempts were also made during the 1970s and 1980s to find a successful, purely restrictive procedure to decrease the stomach reservoir and limit caloric intake without interfering with small intestine anatomy. Printen and Mason introduced a horizontal gastroplasty involving a single staple line along the superior portion of the stomach starting from the lesser curvature [23] (Fig. 4). This formed a small gastric pouch connected to the remainder of the stomach through a channel at the end of the staple line along the greater curvature. Since the stomach reservoir was still able to dilate, adequate weight loss was not achieved, and other attempts with different stapling configurations followed. Gomez added a double-staple technique with mesh reinforcement that often failed due to mesh erosion and obstruction [24]. Pace also attempted to partition the stomach with a horizontal staple, but placed the channel between the upper and lower pouch in the center of the stomach [25]. Nonetheless, this allowed upper pouch dilation due to the thinner nature of the stomach wall near the greater curvature, and such procedures did not lead to lasting weight loss. Surgeons hypothesized that the fixed, thicker lesser curvature may be less likely to dilate. Long and Collins applied this theory by reorienting the staple line adjacent to the greater curvature by the angle of His obliquely toward the lesser curvature [26]. Despite this reorientation and efforts to stabilize the stoma with permanent suture, these procedures had limited success [27].

The gastroplasty variations ultimately led to the vertical banded gastroplasty (VBG) (Fig. 5) performed by Mason in 1980 which involved vertically partitioning the stomach at the angle of His through a window created near to the lesser curvature at the base of the pouch [28]. Polypropylene mesh was then placed around this window to secure the narrow, tubularized stomach reservoir. The VBG eventually was abandoned in favor of other operations such as the Roux-en-Y gastric bypass and adjustable gastric banding. Its drawbacks included stenosis of the pouch outlet due to excessive scarring and reaction to the foreign material, mesh erosion, and subsequent breakdown of the vertical staple line leading to loss of the intended restriction [29, 30].

Wilkinson and Peloso placed the first gastric band in 1978 in New Mexico. This consisted of a 2 cm-wide piece of polypropylene mesh placed around the superior portion of the fundus, restricting the channel for food passage [31]. Many other materials were then used for restriction including: Dacron used by Molina and Oria in Texas, silicone and Marlex mesh used by Näslund in Sweden, and a long 10.5 cm polypropylene clip with steel used by Bashour and Hill in the United States [32]. Although these methods were intended to be less invasive, several complications arose. Specifically, band migration, band erosion, and severe vomiting became significant early problems requiring interventions ranging from endoscopy with dilation to reoperation and revision. Late complications involved pouch dilation similar to that encountered with the earlier gastroplasties. On reoperation, surgeons found that many bands caused significant scarring, and the stoma size could not easily be altered after the first operation. Since the various gastroplasties attempted to this point incorporated staple lines and permanent alterations in gastric anatomy, surgeons across the world attempted to devise less invasive and potentially adjustable gastric restrictive options.

Silicone became the mainstay material for banding in 1983 given findings that it caused less tissue reaction and scarring [33]. Szinicz and Schnapka of Austria made novel modifications to the idea of banding and experimented with adjustable silicone bands in rabbits. Each band contained an inner balloon linked to a subcutaneous port allowing the balloon to be inflated or deflated with saline [34].

In 1985, Hallberg and Forsell of Sweden created an adjustable band to be utilized in humans, ultimately known as the Swedish Adjustable Gastric Band (SAGB) (Ethicon Endo-Surgery, Inc., Cincinnati, OH) [35]. During this same time, Kuzmak of the United States was developing an adjustable gastric band made from inflatable silastic silicone which became the American Band or Lap–Band (Allergan Inc, Irvine, CA)[36]. In 1986, Kuzmak reported the first case of an adjustable gastric band placement. These adjustable bands reduced the trouble of finding the perfect stomal size, since the aperture could now be adjusted through saline injections into a subcutaneous port. This feature made the purely restrictive banding operations much more tolerable by reducing emesis and pressure erosions when band pressures were properly adjusted. Similar weight loss rates were seen early on when compared with the vertical banded gastroplasty [36, 37].

The first minimally invasive weight loss procedure was the laparoscopic placement of a nonadjustable gastric band by Dr. Russell Broadbent in Australia performed on September 10, 1992 [38]. The work of Belachew, Cadiere, O’Brien, and Favretti assisted Inamed in engineering an improved adjustable gastric band. Belachew then placed the first laparoscopic adjustable gastric band on September 1, 1993 [39]. Complications mirrored that of the open gastric banding procedures, including band slippage, pouch dilation, and weight loss failure. Refinements such as the pars flaccid technique helped to decrease the complication [40–42]. This technique involved creation of a smaller stomach pouch and strategic posterior dissection along the diaphragmatic crura. The laparoscopic technique combined with the capability to adjust gastric restriction made this procedure more tolerable for patients than the rigid VBG and yielded a dramatic increase in its popularity. The Lap–Band System (Allergan Inc., Irvine, CA) gained FDA approval in the United States in 2001, and the Realize band (Ethicon Endo-Surgery, Inc., Cincinnati, OH) was introduced in the US market later in the decade. However, the past few years have witnessed a drop in the use of prosthetic restrictive devices due to the high rate of long-term complications, reoperations, and modest weight loss success when compared to other surgical options [43]. The laparoscopic sleeve gastrectomy has largely replaced banding as the preferred restrictive weight loss operation.