Bariatric surgery: past and present

Bariatric operations are either restrictive, limiting the amount of food ingested; malabsorptive, limiting the amount of nutrient absorbed; or a combination of both. Bariatric surgery dates back to the 1950s when jejunoileal bypass was introduced. Since then, numerous improvements have been made in procedures and techniques. Currently, the two most common bariatric procedures performed are laparoscopic adjustable gastric banding and laparoscopic Roux-en-Y gastric bypass. Both of these operations provide excellent results, with the majority of patients losing more than 50% of their excess weight and with most obesity-related comorbidities such as diabetes and hypertension reversed or prevented. Morbidly obese patients considering such operations have to meet strict criteria and must be evaluated by a multidisciplinary team. They need to commit to long-term dietary changes, behavioral modifications, and medical supervision. The choice of procedure is guided by multiple factors, including the patient's and the surgeon's preference.     

Phytochemical malabsorption:clinical significance

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Parasites and malabsorption

In summary, it appears that giardiasis, coccidiosis, cryptosporidiosis, strongyloidiasis, capillariasis and perhaps P. falciparum malaria are the only parasitic diseases which cause malabsorption of many nutrients. D. latum and A. lumbricoides interfere with vitamin B12 and vitamin A absorption, respectively. In view of the increasing use of immunosuppressive therapy, it is likely that malabsorption caused by intestinal parasites may become even more evident in the future.     

Lactose malabsorption and steatorrhea

Twenty-seven patients with an isolated lactase deficienty (ILD) had fecal fat studies on 45 occasions, and 9 individuals had steatorrhea at some level of oral lactose intake. The degree of steatorrhea in the individual patient was related to the amount of lactose ingested. Analysis of the stool triglycerides indicated that the steatorrhea was due to a postlipolytic rather than a lipolytic defect. Steatorrhea was also not related to the presence of diarrhea, as calculated from stool wet-weight, nor was diarrhea related to the amount of dietary lactose ingested. No correlation was found between the presence of an abnormal D-xylose excretion test and lactose-induced steatorrhea. From our data and those in the literature, it would appear that individuals with an ILD who have had gastric surgery or small intestinal resections, or have mucosal abnormalities, are most inclined to develop lactose-induced steatorrhea.Supported in part by Training Grant in Gastroenterology T1 AM-5179 from the National Institutes of Health, by Career Development Award 5 KO3 AMO9693 from the National Institute of Arthritis and Metabolic Diseases and by Part I Research Funds from the Veterans Administration Central Office, Washington, DC.