Roux-en-Y Gastric Bypass (Bariatric Surgery, Weight-Reduction Surgery)

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 historyAttempts to lose weight (about 10%) through medically approved dietary meansOngoing consultations with a registered dietitianMental 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 someof 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. AnesthesiaGeneral anesthesia Description of the ProcedureTo 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 MethodThe open method begins with an 8-10 inch incision to open the abdomen. Laparoscopic MethodThis 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 MethodsBoth 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). Roux-en-Y Gastric Bypass 2008 Nucleus Medical Art, Inc.

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 ProcedureThe breathing tube will be removed and you will be taken to the recovery area for monitoring. Youll 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 tractYou will take multivitamins, vitamin B12, iron, and calcium for the rest of your life.Bleeding ulcermay occur where the small intestine attaches to the pouch; can be managed with medication or may require surgeryAbdominal herniaoccurs in 10%-20% of patients and requires surgical correction; lower risk with laparoscopic surgeryGallstones, which can occur with rapid weight lossgallbladder may be removed during surgery or you may take bile salt supplements after surgeryInfection at the incision areaoccurs in 5% of patientsHeart 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 anesthesiaDeathoccurs in less than 1% of patientsBowel obstructionmay occur if scar tissue forms in the intestinesVomiting due to eating too much or not chewing enough, or scar tissue blocking the new passage between the pouch and small intestineBreakdown of the staples, allowing leakage of stomach juices into the abdomenA pureed diet and eating slowly reduce this risk.Dumping syndrome, which occurs after eating sweetsfood moves too quickly through the small intestine causing sweating, fatigue, lightheadedness, cramping, and diarrheaDiarrhea and abdominal cramping due to eating too much fat Average Hospital Stay2-5 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, youll remain on breathing monitors. Your diet: On the day of surgeryYou will not be given food or drinks. On the day after surgeryYoull have an upper GI x-ray to check for leaks from the stomach pouch; for this test, youll drink a special liquid while x-rays are taken. If the upper GI x-ray is normal, youll be given 30 milliliters (mL) of liquids every 20 minutes.If leaks are found, youll receive nutrition through an IV until the leaks are resolved.On the second day after surgeryYoull 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 HomeYou 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. Youll 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.Youll 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, youll 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 PepcidActigall, if your gallbladder has not been removed Pain medicationVitamin 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 reductionIn 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 conditionssuch as glucose intolerance, diabetes, sleep apnea, high blood pressure , and high cholesterolImproved mobility and staminaEnhanced mood, self-esteem, and quality of life AlternativesFor 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)Vertical banded gastroplastyLaparoscopic adjustable gastric bandingDuodenal switchEach 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 chillsRedness, swelling, increasing pain, excessive bleeding, or discharge from the incision siteCough, shortness of breath, chest pain, or severe nausea or vomitingWorsening abdominal painBlood in the urine or stoolPain, burning, urgency, or frequency of urination, or persistent bleeding in the urinePersistent nausea and/or vomitingPain and/or swelling in your feet, calves, or legs, or sudden shortness of breath or chest painAny other worrisome symptoms RESOURCES:

American Society for Metabolic and Bariatric Surgeryhttp://www.asbs.org/ National Institutes of Healthhttp://health.nih.gov/ Weight Control Information Networkhttp://www.win.niddk.nih.gov/ CANADIAN RESOURCES: BC Health Guide, British Columbia Ministry of Healthhttp://www.bchealthguide.org/ Canadian Laparoscopic Weight Loss Surgeryhttp://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. Last reviewed October 2007 by Daus Mahnke, MDPlease 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.