Brief History
Gastric Bypass is the most commonly Bariatric Surgery performed worldwide. Seventy per cent of the Bariatric Surgeries performed in the world are Gastric Bypass. It is also known as Fobi-Capella Surgery or Gastric Septation.

In the 1960s, Drs. Mason (father of Bariatric Surgery) and Ito, two American surgeons, noticed that patients who had undergone gastrectomy surgery (the removal of part or all the stomach) for gastroduodenal ulcer treatment lost weight. They came to the conclusion that the resulting weight loss after the operation had a double factor: first, the downsizing of the stomach to a 100 ml volume organ; secondly, food would not pass through duodenum and initial jejunum. So, they decided to perform the same kind of procedure in the morbidly obese patients to intentionally cause weight loss. Soon afterward, in 1967, it was the beginning of Gastric Bypass era for the obesity treatment.

In 1986, Dr. Mal Fobi introduced a variation of the same technique, in which the stomach was not removed from the body, that is, food would pass through a partly reduced stomach, but the rest of the organ continued there. So, the stomach was divided in two separated parts, a 100 ml stomach, called pouch, and a 1500 ml one, where food would not go inside, called excluded stomach. The technique modification brought two advantages. One was that surgery was performed in shorter period of time, which would be important to reduce cardiopulmonary complications already worsened by obesity. The other one was that complications from a gastrectomy were also avoided. Dr. Fobi also created a silicone ring that restrained stomach dilatation.

Note: By not removing any parts of the stomach, it is a fully "reversible" surgery.

In 1991, Dr. Rafael Capella suggested that pouch size should be decreased from 100 to 20 ml, and pouch would be protected by small intestine to avoid fistulas (leakage). Instead of using the silicone ring, he utilized a strip of polypropylene mesh. This was called Fobi-Capella Technique.

In 1994, Drs. Wittgrove and Clark performed the first Videolaparoscopic Gastric Bypass. The only difference from Fobi-Capella technique was the absence of the silicone ring or the polypropylene strip. Until now, Videolaparoscopic Gastric Bypass is known as the "Gold Standard" of Bariatric Surgery.

Action Mechanism
This kind of surgery provides a double action mechanism, as explained in Bariatric Surgery: ileal nutrition and gastric reduction.

Ileal Nutrition

Ileal Nutrition means "to make the food get into the terminal small intestine". When food gets in the terminal small intestine (ileum), some hormones start being produced. Those hormones warn the satiety center of the brain that there is already enough food, and the person stops eating. The same hormones make the same food goes backwardly to the stomach, which causes stomachal discomfort, i.e., fullness sensation. Such hormones also improve the insulin production of a tired pancreas, bettering diabetes 2 condition.

As seen before, modern food (rich in carbohydrates and poor of fiber contents) is easily absorbed in the duodenum and proximal jejunum (highly absorptive parts of the intestine). So, great part of the ingested modern food passes quickly from those parts of the intestine into the blood. Unfortunately, this sort of food does not go into the terminal portion of the small intestine, and in turn, the intestine does not sign the brain that there is enough food and people keeps eating more and more and still feeling hungry.

Gastric Bypass creates a "shortcut" in the digestive tube. Food passes through a reduced stomach, which is sutured to the medium jejunum. In other words, food does not pass through major part of stomach, duodenum, and 70 cm of initial jejunum. Such modification stops the intense food absorption in that area. Then, food goes to the terminal small intestine, sending a conspicuous indication to the brain and soon after the beginning of meal, hunger decreases. This is the main weight loss mechanism of Gastric Bypass. Perhaps 95% of patients who underwent the procedure do not feel much hungry anymore. This feature seems to be kept forever, according to the report of patients who underwent gastrotectomy due to ulcers, operation performed since 1880.

Gastric Reduction

The functional stomach (pouch) is very small, around 20 ml, and food passage from this pouch to the intestine is delayed by any "disturbing factor", like a ring or calibrated suture. The operated patient feels that he/she must wait a couple of seconds between two deglutitions, like in an hourglass that sand needs time to fall down into the bottom part. Patient feels full with little ingested food. The disturbing factor is important for the patient to learn eating slowly which causes gastric satiety. However we do not over tighten any of them, in order to prevent patient from vomiting, which would decrease the patient's quality of life. The operated patient has to be able to eat any kind of food, except fruit pulp that might clog the intestine.

We, Franco e Rizzi Clinic, prefer to utilize the calibrated suture, because in case of over cicatrization, which might narrow the food passage, we can perform an ambulatorial endoscopic dilatation of the gastrojejunal anastomosis (the surgical connection between pouch and intestine).

Although the calibrated suture is also important to avoid psychological eating compulsion, if it is too tighten, it may cause vomiting. That ends up instructing the patient to eat sweets, due to fiberless contents (they pass easily through the pouch), over meat and vegetables. Therefore, over tightened suture may cause weight gain.

Results
The purpose of Bariatric Surgery is the loss of approximately 40 to 45% of initial weight, in approximately 7 months. To achieve such purpose, patient must exercise to burn calories acquired long before. There is no use starting physical activities after that period, because we have a limited period of 7 months, that starts right after surgery, for the potential weight loss. We suggest that patient swims or walks, since those activities do not cause high-impact joint injuries. A broken leg during this period could jeopardize all the process. Also, during this period, any kind of sweet ingestion is prohibitive, because that ingestion would get in the way of the purpose of burning old fat. After achieving ideal weight, probably within 7 months, patient has a "new general balance point", with a reasonable thinner body, probably not feeling hungry and having new sources of pleasure. Under those new conditions, it is allowed to eat sweets and also less physical activity is permitted.

The proposal is to offer a good quality of life:

• Probably patient does not suffer from hunger; many patients, occasionally, skip a meal, by just forgetting about it;

• Eating stops being the greatest source of pleasure, since patient is not hungry anymore. As nobody is capable of living without pleasure, patient ends up finding another substitute source, like dancing, dating, practicing sports and so on;

• Patient does not vomit frequently, since the suture aims the passage of any sort of food, except fruit pulp. Patient must eat slowly, in a quiet environment;

• Usually patient does not present diarrhea and feces do not have strong odor.