Roux-en-Y Gastric Bypass - Minimally Invasive Gastric Bypass performed by Skilled Bariatric Surgeons

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This operation is the most common bariatric surgery procedure.  First, a small stomach pouch is created, which causes restriction of food intake. Next, a lower section of the small intestine is attached to the pouch, to allow food to pass to the intestines. Most of the stomach and upper portion of the intestines is "bypassed," which causes mild reduction in nutrient absorption.

What does the name mean?
The operation is named after a common method of using small intestines as a means to bypass (re-route) food or gastrointestinal secretions. It was first described by Cesar Roux (1857-1934) as a means to bypass a blocked stomach caused from severe scar tissue after peptic ulcer attacks. The "Y" comes from the vague similarity the stick figure representation of the procedure has to the letter. The Roux-en-Y procedure has over the years been modified for use in many surgical procedures including liver transplants, pancreas operations, and cancer operations of the stomach and bile ducts. Often people simply call the procedure a gastric bypass or an RNY.

What is new with this procedure?
The gastric bypass has had a remarkable resurgence in popularity after the introduction of the minimally invasive techniques. Qualified and specially trained surgeons can do this operation with lower complications than the best open surgeons. On average, a surgeon should have performed 100-200 cases laparoscopically before he can be deemed proficient in the operation. At The NEW Program at Community Hospital of Long Beach, our experience far exceeds this.

Are there important aspects of the anatomy that help with long term weight control?
Yes. The original size of the pouch is important-if it is too large it may enlarge substantially over time and result in becoming a "second stomach." The most common initial size of the pouch is 10-20cc - less than an ounce. The small pouch must also be created in such a way that it has a small outlet. This outlet is also called a "stoma."

For the gastric bypass, the surgeon should be meticulous in creating the outlet correctly since small differences in technique may result in outlet, or stomal, enlargement. If the outlet is too large, food will not remain in the pouch long enough to provide the feeling of satiety (lack of hunger). Maintaining that feeling of satiety requires keeping the pouch stretched for a while after each meal. This also involves not drinking during, or shortly after, meals. High calorie liquids (concentrated juice, milk shakes, thick cream soups, etc...) will result in weight gain.

Some surgeons believe that changing the length of the roux limb may result in additional weight loss. The roux limb length is defined as the amount of intestine from the stomach to the hook-up (anastomosis) of the intestine. We may increase the length of the roux limb in patients whose BMI is greater than 50. Weight regain after the gastric bypass was common years ago when the gastric pouch was made quite large. Today, inexperienced surgeons may make the pouch large because they are uncomfortable with the techniques. At The NEW Program at Community Hospital of Long Beach, we have not experienced any patient that has had significant weight regain after the gastric bypass.

Will I be able to eat normally after the gastric bypass?
You will certainly eat differently. Patients experience significant lack of hunger after the gastric bypass. This is most significant immediately after the operation, but improves some with time. Patients also become very full (satiated) after eating small amounts of food. After a gastric bypass people generally are satisfied with the foods that they eat, they generally can eat regular food (with the exception of sweets) and many of their previous cravings are gone. In the first few months after the operation, patients have to adapt to their new eating style. There is a lot of trial and error in food selection. Within a few months, eating becomes much easier.
 
What is dumping?
Dumping usually occurs when concentrated sugar, or highly concentrated carbohydrates enter the upper intestine without being broken down by pancreatic juice and bile. Since these fluids mix with ingested food further downstream than usual after the gastric bypass, dumping generally occurs if a patient eats concentrated sweets. The syndrome typically involves 15 minutes to one hour of intestinal cramping, diarrhea, sweating, a fast heart rate and other side effects. Dumping can sometimes happen with other foods as well. Dumping does not occur after gastric band placement or the Biliopancreatic Diversion with Duodenal Switch (BPD-DS). We view dumping as a good side effect that improves a patient's weight loss.

What are the expected results?
On average, after a gastric bypass, patients will loss about 70-80 percent of their excess weight during a 2-year period. Weight loss is extremely rapid during the first 6 months and then tapers down. Some patients will regain 5-10 percent of their excess weight during the two to five year mark. The reason for this weight regain in some patients is complex and poorly understood. Long-term studies have consistently documented continual weight loss over a ten to twenty-year follow-up period. This is one of the best studied operations for weight loss.



What complications can occur after my procedure?
The most common late complication after a gastric bypass is iron deficiency anemia. Some patients will require long term iron supplementation in addition to the usual multivitamin. Osteoporosis may occur at a higher frequency in gastric bypass patients, and calcium supplements are recommended in some patients. Rarely, internal hernias can occur long after a gastric bypass. These may require operative interventions.

In the first several months after a gastric bypass, two percent of patients develop strictures. This is scarring between the stomach and the intestine. People notice that liquids "go down" easily, but solids tend to stick. This complication can be easily remedied by an endoscopy performed by the gastroenterologist in the office. Ulcers occur in some patients - especially smokers and patients that take NSAIDS (Motrin, Aleve, Advil, Naproxen, etc...). Ulcers can cause bleeding or pain. Medications often help ulcers heal.

In the first week of a gastric bypass several potential complications are possible. The death rate in experienced centers is about 1/500 - 1/1000. In inexperienced hands, the death rate can be as high as 1 in 50. The most common cause of death is a pulmonary embolism (PE). PE's can occur after any general anesthesia and major operation. Early mobilization and the use of blood thinners can decrease the likelihood of this serious complication.  A "leak" is when intestinal fluid spills out from where the stomach and intestines are connected. This complication can result in peritonitis. This complication occurs in 0.5% of patients in experienced hands. Our leak rate is less than this. Leaks can be managed by a number of methods - sometime requiring a re-operation. Bleeding is a complication that requires transfusion in 1% of patients. Bleeding rarely requires re-operation. Nausea that lasts for more than several days is uncommon. Rarely nausea lasts for several weeks. Nausea always resolves with a time. There are numerous potential complications with gastric bypass (some serious and some not) that can occur after any operation. Our highly experienced, skilled and friendly surgeons will discuss these with you during your pre-op education and visits. Attend an information seminar and meet Drs. Quebbemann and Braveman.

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