The origin of the «simplified gastric bypass»

Mr. Publisher,

Not long ago, an article by Hernández-Miguelena et al.¹, entitled “Simplified laparoscopic gastric bypass. Initial Experience.” (Bypass gástrico laparoscópico simplificado. Experiencia inicial)¹ was published, in which the authors briefly and intelligibly shared the group's 4-year experience (2008-2012) that included 90 patients undergoing surgery using said surgical technique. I believe it is an important article for our country's medical literature and an example of positive results for handling these types of patients. However, it is important to address an inaccuracy connected with the history and the initial description of the surgical technique mentioned above (“simplified” gastric bypass).

The use of the “simplified gastric bypass” is frequently covered at congresses, lectures, sessions and articles related to bariatric surgery, since it is easy to replicate, in comparison with other techniques. In a previous publication², both Dr. Hernández-Miguelena and Dr. Prieto-Aldape express that the aforementioned technique was described by Dr. Almino Ramos, in a publication from the Revista Mexicana de Cirugía Endoscópica in the year 2004. Firstly, it is essential to explain that such publication does not exist. However, there is only a summary of a poster presented at the Congress of Endoscopic Surgery of said year, included in the publisher's supplement³; the bibliographic quote is wrong in both articles.

The importance lies in the true origin of this surgical technique, which has mistakenly been ascribed to Dr. Ramos’ group. The concept of a simplified gastric bypass is not entirely based on the placement of the trocars, as the authors express, but on the original construction of an omega loop bypass that at the end of the surgery turns into a Roux-en-Y gastric bypass. The advantage of said technique is that the whole surgery is performed at a supramesocolic level, having visual control of both anastomoses and being ergonomically superior to others.

This bypass was originally described by Dr. Hans Lönroth, from the Department of Surgery of the Sahlgrenska University Hospital in Gothenburg, Sweden (2003)⁴. Dr. Lönroth's team is a pioneer in the field of bariatric surgery and described its first experience with laparoscopic bypass almost 20 years ago (1996)⁵, initially performing an omega loop bypass (Fig. 1A). In a later publication (2003) from said group, titled “Laparoscopic gastric bypass: Development of technique, respiratory function, and long-term outcome,” the modification of the original technique was mentioned for the first time. They described 150 cases, in which the last 102 patients were operated on using a technique that consisted of an antecolic-antegastric gastrojejunal anastomosis (with omental division), as well as an entero-entero anastomosis with omega loop and a final conversion to a Roux-en-Y gastric bypass when cutting the intestine between both anastomoses (Fig. 1B). They also concluded that this technique was established after different modifications, until it became technically simpler.

Fig. 1.

A) Omega loop gastric bypass described in 1996. B) Simplified Roux-en-Y gastric bypass described in 2003. The white arrow points to the food handle; the grey arrow points to the biliary handle; the dotted arrow points to the common handle; the black arrow points to the section location between both handles at the end of the surgery. Adapted from Lönroth et al.⁵

Through the evolvement of different bariatric surgeries, work tools and the global expansion of this speciality throughout the years, we have developed a safe surgery model. Dr. Lönroth's contribution of a “simpler” and easy-to-replicate surgical technique constitutes a key piece in bariatric surgery history, which is why it should not be forgotten or ignored. The importance of Dr. Almino Ramos’ team lies in that they disseminated the use of said technique around the world, especially in Latin America.