Laparoscopic Gastric Bypass (Roux-en-Y)

 

In recent years, better clinical understanding of procedures combining restrictive and malabsorptive approaches has increased the choices of effective weight loss surgery for thousands of patients. By adding malabsorption, food is delayed in mixing with bile and pancreatic juices that aid in the absorption of nutrients. The result is an early sense of fullness, combined with a sense of satisfaction that reduces the desire to eat.

According to the American Society for Bariatric Surgery and the National Institutes of Health, Roux-en-Y gastric bypass is the most frequently performed weight loss surgery in the United States. In this procedure, stapling creates a small (15 to 20cc) stomach pouch. The remainder of the stomach is not removed, but is completely stapled shut and divided from the stomach pouch. The outlet from this newly formed pouch empties directly into the lower portion of the jejunum, thus bypassing calorie absorption. This is done by dividing the small intestine just beyond the duodenum for the purpose of bringing it up and constructing a connection with the newly formed stomach pouch. The other end is connected into the side of the Roux limb of the intestine creating the "Y" shape that gives the technique its name. The length of either segment of the intestine can be increased to produce lower or higher levels of malabsorption.

Approximate weight loss

Patients who undergo Roux-en-Y gastric bypass generally achieve an excess weight loss of approximately 70 - 80%, but this can vary. This is dependent on following the diet recommendations appropriately.

Estimated hospital release and recovery times

Gastric bypass patients generally require a hospital stay of about 2 nights, although this can vary slightly. Recovery time is usually between 4-6 weeks.

Advantages

• The average excess weight loss after the Roux-en-Y procedure is generally higher in a compliant patient than with purely restrictive procedures.
• One year after surgery, weight loss can average 72% of excess body weight.
• Studies show that after 10 to 14 years, 50-70% of excess body weight loss has been maintained by most patients.

Complications

All major surgery involves a certain level of risk, including death. However, mortality related to bariatric surgery is often cited in the context of the debate about whether the procedure should be performed. A recent meta-analysis published in the Journal of the American Medical Association of more than 3000 patients reported a combined mortality rate of 0.14% for restrictive procedures, such as gastric banding, and 0.3% for combination procedures, such as Roux-en-Y gastric bypass). Early complications in gastric bypass include leaks at one of the two anastomoses (where the anatomy has been connected by stapling or suturing). This is a serious complication, even if detected early. Later complications can include (among others) bowel obstruction, nutritional deficiency, anastomotic stricture (scarring), and changes in pouch size. Once you have undergone Roux-en-Y gastric bypass, it is difficult to reverse and should be considered permanent. Canadian data published by Dr. Nic Christou showed that in a 5-year period, obese patients who did not have surgery were 10 times more likely to die of any cause than patients who did have the operation.

Risks

(The following are in addition to the general risks of surgery)

• Because the duodenum is bypassed, poor absorption of iron and calcium can result in the lowering of total body iron and a predisposition to iron deficiency anemia. This is a particular concern for patients who experience chronic blood loss during excessive menstrual flow or bleeding hemorrhoids. Women, already at risk for osteoporosis that can occur after menopause, should be aware of the potential for heightened bone calcium loss.
• Bypassing the duodenum has caused metabolic bone disease in some patients, resulting in bone pain, loss of height, humped back and fractures of the ribs and hip bones. All of the deficiencies mentioned above, however, can be managed through proper diet and vitamin supplements.
• A chronic anemia due to Vitamin B12 deficiency may occur. The problem can usually be managed with Vitamin B12 pills or injections or oral B12 supplements.
• A condition known as "dumping syndrome" can occur as the result of rapid emptying of stomach contents into the small intestine. This is sometimes triggered when too much sugar or large amounts of food are consumed. While generally not considered to be a serious risk to your health, the results can be extremely unpleasant and can include nausea, weakness, sweating, faintness and, on occasion, diarrhea after eating. Some patients are unable to eat any form of sweets after surgery.
• In some cases, the effectiveness of the procedure may be reduced if the stomach pouch is stretched and/or if it is initially left larger than 15-30cc.
• The bypassed portion of the stomach, duodenum and segments of the small intestine cannot be easily visualized using X-ray or endoscopy if problems such as ulcers, bleeding or malignancy should occur.
• Rapid weight loss can lead to the formation of gallstones. In some patients, the gallstones can cause a number of problems that may require a gall bladder operation