Roux-en-Y gastric bypass is a surgical treatment for
obesity. It changes the stomach and small intestine to cause weight loss by: 1) restriction of caloric intake and 2) malabsorption of calories.
Intake is restricted by creating a small pouch to serve as the stomach. Malabsorption occurs because the first part of the small intestine, where many calories are normally absorbed, is bypassed.
Parts of the Body Involved
Stomach
Small intestine
Reasons for Procedure
The reason for the surgery is to treat morbid obesity (also called clinically severe obesity). Doctors use a calculation called body mass index (BMI) to determine overweight or obesity. BMI uses an equation to compare your height and weight to decide whether your weight is normal or not. A normal BMI is 18.5-25. If your BMI is 40 or more, you are at least 100 pounds over normal weight for your height.
Roux-en-Y gastric bypass may be appropriate for people with the following factors:
BMI greater than 40, or 100 pounds overweight
BMI 35-39.9 and a life-threatening condition, such as heart disease or
diabetes
BMI 35-39.9 and severe physical limitations that affect employment, mobility, and family life
Risk Factors for Complications During the Procedure
Obesity increases the risk for complications during any surgical procedure.
What to Expect
Prior to Procedure
Each bariatric surgery program has a specific plan to prepare you for surgery and for your lifestyle changes after surgery. Your program will likely include:
Thorough physical exam and review of medical history
Attempts to lose weight (about 10%) through medically approved dietary means
Ongoing consultations with a registered dietitian
Mental health evaluation and counseling
In the days leading up to your procedure:
Review your regular medications, herbs, or dietary supplements with your surgeon; you may need to temporarily discontinue some
of these products.
Do not start taking any new medications, herbs, or supplements without talking to your doctor.
Arrange for a ride to and from the hospital.
Arrange for help at home as you recover.
You may be given antibiotics to take before coming to the hospital.
You may be given laxatives and/or an enema to clear your intestines.
The night before your surgery, eat a light meal and do not eat or drink anything after midnight unless told otherwise by your doctor.
Shower or bathe the morning of your surgery.
Bring all your medications with you to the hospital.
To prepare you for surgery, an intravenous (IV) line will be placed in your arm. You may receive fluids and medications through this line during the procedure. A breathing tube will be inserted through your mouth and into your windpipe. This will help you breathe during surgery. You will also have a catheter placed in your bladder to drain urine.
There are two surgical methods used for Roux-en-Y gastric bypass:
Open Method
The open method
begins with an 8-10 inch incision to open the abdomen.
This method
begins with several small incisions in the abdomen. Gas is pumped in to inflate your abdomen, making it easier for the surgeon to see. Your surgeon passes a laparoscope and surgical tools through these incisions. A laparoscope is a thin, lighted instrument with a tiny camera that projects images of your abdominal cavity on a monitor in the operating room; your surgeon performs the operation while viewing the surgical area on this monitor.
Both Methods
Both methods proceed as follows: Your surgeon uses surgical staples to create a small pouch at the top of your stomach. This pouch, which can hold about one cup of food, will serve as your new, smaller stomach. A normal stomach can hold 4-6 cups of food.
Next, the surgeon cuts a section of the small intestine and attaches it to the newly created pouch. This intestinal bypass moves food directly from the pouch to the middle section of the small intestine (jejunum), skipping the lower stomach and the upper section of the small intestine (duodenum).
This procedure has both restrictive and malabsorptive effects. It is restrictive because the smaller pouch can only handle one-sixth the amount of food as a normal size stomach. And it is malabsorptive because the duodenum, where many calories are absorbed, is bypassed. The result: fewer calories are taken in and fewer calories are absorbed.
To complete the procedure, your surgeon will close the incisions with staples or stitches.
After Procedure
The breathing tube will be removed and you will be taken to the recovery area for monitoring. You’ll be given pain medication.
How Long Will It Take?
Two hours
Will It Hurt?
Anesthesia prevents pain during surgery.
Patients typically experience pain and/or soreness at the incision sites during recovery. Your doctor can prescribe pain medication to relieve the discomfort.
Possible Complications
Risks associated with Roux-en-Y gastric bypass include:
Nutritional deficiencies due to changes in the natural flow of the digestive tract
Bleeding ulcer—may occur where the small intestine attaches to the pouch; can be managed with medication or may require surgery
Abdominal hernia—occurs in 10%-20% of patients and requires surgical correction; lower risk with laparoscopic surgery
Gallstones, which can occur with rapid weight loss—gallbladder may be removed during surgery or you may take bile salt supplements after surgery
Infection at the incision area—occurs in 5% of patients
Heart and lung problems
Blood clots in the vein (phlebitis) or traveling to the lungs (embolism)
Blood thinners before and after surgery, and elastic surgical stockings during recovery reduce this risk.
Complications of general anesthesia
Death—occurs in less than 1% of patients
Bowel obstruction—may occur if scar tissue forms in the intestines
Vomiting due to eating too much or not chewing enough, or scar tissue blocking the new passage between the pouch and small intestine
Breakdown of the staples, allowing leakage of stomach juices into the abdomen
A pureed diet and eating slowly reduce this risk.
Dumping syndrome, which occurs after eating sweets—food moves too quickly through the small intestine causing sweating, fatigue, lightheadedness, cramping, and diarrhea
Diarrhea and abdominal cramping due to eating too much fat
Average Hospital Stay
2-5 days (Shorter stay after a laparoscopic procedure than an open procedure)
Postoperative Care
At the Hospital
While you are recovering at the hospital, you may receive the following care:
Pain medication will be given as needed.
If you have
sleep apnea, you’ll remain on breathing monitors.
Your diet:
On the day of surgery—You will not be given food or drinks.
On the day after surgery—You’ll have an
upper GI x-ray
to check for leaks from the stomach pouch; for this test, you’ll drink a special liquid while x-rays are taken.
If the upper GI x-ray is normal, you’ll be given 30 milliliters (mL) of liquids every 20 minutes.
If leaks are found, you’ll receive nutrition through an IV until the leaks are resolved.
On the second day after surgery—You’ll take 1-2 tablespoons of pureed food or 1-2 ounces of liquids every 20 minutes.
While in the hospital, you may be asked to do the following:
Use a spirometer to take deep breaths every hour to prevent breathing problems.
Wear elastic surgical stockings to promote blood flow in your legs.
Get up and walk in the hall daily.
At Home
You may be out of work for 2-6 weeks after gastric bypass surgery (less time with laparoscopic, and more time following an open procedure). Do not drive or lift anything heavy for at least two weeks. You’ll need to practice lifelong healthful eating and exercising habits.
You are encouraged to walk as soon as possible, with a goal of exercising daily. Be aware that you may have emotional ups and downs after this surgery. You will meet regularly with your healthcare team for monitoring and support.
Your new stomach is the size of a small egg and is slow to empty, causing you to feel full quickly. Therefore, you need to eat very small amounts and eat very slowly.
You’ll begin with 4-6 meals per day; a meal is two ounces of food. For the first 4-6 weeks after surgery, all food must be pureed. Once you move to solid foods, food must be chewed well. When making food choices, you’ll need to ensure adequate protein intake, while limiting sweets and fatty foods. Eating too much or too quickly can cause vomiting or intense pain under your breastbone. Most people quickly learn how much food they can tolerate.
You may need to take the following medications, as directed by your doctor:
Antacids, such as
Zantac
or
Pepcid
Actigall, if your gallbladder has not been removed
Pain medication
Vitamin and mineral supplements
Outcome
The success of gastric bypass surgery depends on your commitment to lifelong healthful habits. If lifestyle changes are made and maintained, the benefits of bariatric surgery include:
Long-term, consistent weight reduction—In the first 12-24 months, most people lose 50%-70% of their excess weight and keep it off for 10 years or longer
Improvement in many obesity-related conditions—such as glucose intolerance, diabetes, sleep apnea,
high blood pressure
, and
high cholesterol
Improved mobility and stamina
Enhanced mood, self-esteem, and quality of life
Alternatives
For severe obesity (BMI 40 or greater), surgery is a successful treatment. There are, however, several competing surgical procedures. These include:
Roux-en-Y gastric bypass (the procedure discussed in this article)
Each of these procedures has benefits and drawbacks. Be sure to discuss all surgical options with your doctor so that you can understand all of the choices available to you.
Call Your Doctor If Any of the Following Occurs
It is important for you to monitor your recovery once you leave the hospital. That way you can alert your doctor to any problems immediately. If any of the following occur, call your doctor:
Signs of infection, including fever and chills
Redness, swelling, increasing pain, excessive bleeding, or discharge from the incision site
Cough, shortness of breath, chest pain, or severe nausea or vomiting
Worsening abdominal pain
Blood in the urine or stool
Pain, burning, urgency, or frequency of urination, or persistent bleeding in the urine
Persistent nausea and/or vomiting
Pain and/or swelling in your feet, calves, or legs, or sudden shortness of breath or chest pain
Any other worrisome symptoms
RESOURCES:
American Society for Metabolic and Bariatric Surgery http://www.asbs.org/
National Institutes of Health http://health.nih.gov/
Weight Control Information Network http://www.win.niddk.nih.gov/
CANADIAN RESOURCES:
BC Health Guide, British Columbia Ministry of Health http://www.bchealthguide.org/
Canadian Laparoscopic Weight Loss Surgery http://www.weightlosssurgery.ca/
References:
Gastrointestinal surgery for severe obesity. National Institute of Diabetes and Digestive and Kidney Diseases website.Available at:
http://win.niddk.nih.gov/publications/gastric.htm
. Accessed June 18, 2008.
Laparoscopic gastric bypass procedure. Cleveland Clinic website. Available at:
http://www.clevelandclinic.org/health/health-info/docs/1900/1993.asp?index=4355
. Accessed June 18, 2005.
Laparoscopic Roux-en-Y. Baylor College of Medicine website. Available at:
http://www.debakeydepartmentofsurgery.org
. Accessed June 18, 2005.
Obesity risks add to complications of gastric bypass [news release]. Duke University Medical Center website. Available at:
http://www.dukemednews.org/news/article.php?id=7217. Accessed June 20, 2005.
Obesity surgery. Columbia University website. Available at:
http://www.columbiasurgery.org/divisions/obesity/index_obe.html
. Accessed June 20, 2005.
Obesity surgery. Ohio State University website. Available at:
http://surgery.osu.edu/generals/obesity.cfm. Accessed June 20, 2005.
Rationale for the surgical treatment of morbid obesity.
American Society for Bariatric Surgery website. Available at:
http://www.asbs.org/html/rationale/rationale.html. Accessed June 17, 2005.
Surgery for obesity: what is it and is it for you? Mayo Foundation for Medical Education and Research website.Available at:
http://www.mayoclinic.com/invoke.cfm?id=HQ01465. Accessed June 18, 2005.
Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.
