THE ROUX-EN-Y GASTRIC BYPASS (RYGB)
INTRODUCTION
The Roux-en-Y gastric bypass remains the gold standard to which other weight loss operations are compared. It is the oldest, and best studied weight loss operation. It is the second most frequently performed weight loss operation in the United States, after the sleeve gastrectomy. The gastric bypass takes advantage of both restriction and malabsorption to work. The restrictive part of the procedure is the creation of the small stomach pouch with a very small outlet. The stretchable part of the stomach is no longer used. The malabsorptive part of the procedure involves re-arranging of the small intestine to reduce how much of the intestine is involved in absorbing the small amount of food that is eaten. The operation also causes metabolic effects – which has great health benefits and improves weight loss even further. The most dramatic metabolic impact the RYGB operation has, is on diabetes. Even before any significant weight has been lost the diabetes has already improved and requires less medication to manage.
The entire procedure is performed laparoscopically. The small stomach pouch is created by stapling. The pouch is created to be long and narrow. The small intestine is then rearranged - one cut end of the bowel is connected to the pouch, while the other cut end, is reconnected to the small bowel about 100 to 150cm from the pouch. The result is a "Y" shaped re-connection 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.
The operation restricts food intake very effectively, particularly during the first year, the time of maximum weight loss. Ultimately, a bypass patient will be able to eat about 4 ounces of food per meal 3 to 4 times a day while experiencing prolonged satisfaction and fullness from that small amount of food. Hunger and cravings are controlled, particularly if the patient is compliant with the rules. This is a profound experience for many, being released from a prison of hunger.
The weight loss is projected to be 70% of the excess body weight. The greatest weight loss is expected to occur over the first one to one and half years. Half of the expected weight loss is lost in the first six months after surgery. Studies show patients typically lose the most weight 1-2 years after bariatric surgery and see substantial weight improvements in obesity-related conditions.
- Patients may lose as much as 60% of excess weight six months after surgery, and 77% of excess weight as early as 12 months after surgery.
- On average, five years after surgery, patients maintain 50% of their excess weight loss.
With good compliance, an 80% chance of maintaining the weight loss long-term can be expected, and 80% to 90% of patients have at least improvement and/or resolution of their medical problems.
Proceeding with weight loss surgery is a very personal and often difficult decision. Educating yourself about weight loss surgery is a very important first step. If you are ready to meet with the surgeon, schedule a first visit appointment by calling the office at 913-322-7401 or request a new patient appointment via our website.
For those of you who may be traveling large distances to visit us, please inform our staff you are traveling so they can prepare you better and help you minimize the number of trips that may be required to get you ready for your weight loss operation.
AM I A ROUX-EN-Y GASTRIC BYPASS SURGERY CANDIDATE?
To be a candidate for any type of weight loss surgery, the individual must be severely (BMI > 35) or morbidly (BMI > 40) obese. If diabetes is present and it is not well controlled patients can qualify with a BMI > 30. Morbid obesity is usually defined as being about 100 pounds over your ideal body weight. A better way of defining morbid obesity is by using the Body Mass Index (BMI). BMI is a calculated number that takes weight and height into consideration. A person weighing 300 pounds who is 5ft tall will have a higher BMI than a person weighing 300 pounds but is 6 ft tall.
To determine if you qualify for the Roux-en-Y Gastric Bypass, you can start by entering your weight and height into a BMI calculator.
Insurance companies often will have additional criteria to qualify for weight loss surgery. Our office can help you determine what those are. Below you will find the basic criteria most insurance companies use to determine if patients qualify for weight loss surgery:
BMI ≥ 40 regardless of medical problems
BMI ≥ 35 usually with medical problems such as:
- type II diabetes (T2DM),
- hypertension,
- sleep apnea and other respiratory disorders,
- non-alcoholic fatty liver disease,
- osteoarthritis,
- lipid abnormalities,
- gastrointestinal disorders, or
- heart disease.
BMI > 30 If Diabetes type II is not well controlled. Unfortunately most insurance companies are not yet covering for this criteria
In addition:
No endocrine causes of obesity (untreated hypothyroidism, etc.).
There is an acceptable operative risk (the procedure does not put the patient at undue risk).
The patient understands the surgery and its risks.
The patient does not have a drug or alcohol addiction.
The patient does not have uncontrolled psychological conditions.
The patient should have tried other attempts at weight-loss (diets, exercise, medications, counseling, etc.…..).
THE ROUX-EN-Y GASTRIC BYPASS PROCEDURE
The gastric bypass operation is performed laparoscopically. Five small incisions are required to perform the operation. The first part of the operation is the creation of the small new stomach or “pouch”. With modern stapling devices, pouches are made as small as the size of your thumb. The pouch is created from the very top portion of your stomach and it is completely separated from your old stomach. A large part of the old stomach can be removed to enduce more metabolic effects and improve weight loss by reducing hunger. The old stomach remains a viable organ, but it does not see food anymore. By leaving your old stomach inside, the bypass operation can be reversed if the need should arise.
Once the pouch is created, the second step is to perform the intestinal bypass part of the operation. This means the intestine is rearranged to reduce the amount of intestine involved in absorbing food without removing any intestine. The point where the digestive enzymes mix with the food is delayed or moved further downstream. The point is approximately 100 cm from the pouch. To accomplish this the intestine is divided in one place and two connections need to be made to allow the digestive enzymes to meet with the food. The name Roux-en-Y gastric bypass comes from the way the anatomy appears when completed. The bowels are arranged in a Y shape, and approximately 150 cm of intestine are no longer involved in true digestion, or in other words, bypassed from food.
HOW DOES THE GASTRIC BYPASS WORK?
The bypass maintains the principles of restriction and malabsorption with the associated metabolic effects. The small pouch and narrow outlet restrict food intake and maintain satiety, while the re-arranging of the small intestines allows for less digestion time. The combination of these two procedures results in additional weight loss compared to a restrictive operation alone, for example, the Lap-Band. Restriction remains the key to major weight loss.
The size of the pouch limits how much food you can eat, while the size of the outlet controls how quickly it can empty. The smaller the outlet, the longer it will take for food to leave the pouch. The longer the pouch is full, the longer you experience satiety and no hunger. Once the food exits the pouch into the small intestine, the malabsorptive component begins. By bypassing parts of the intestine, food is now delayed from mixing with the digestive enzymes. The food may not be digested completely and the food that is digested has less time to be absorbed because there is less bowel to absorb it. The digestion of food starts at a later point than normal. The point where the biliopancreatic limb is connected to the food conducting limb can vary to produce more or less malabsorption. More bypassed bowel increases risk and side-effects.
Surgery alone will not ensure long-term weight loss. Surgery is a great tool to help patients do the work to reach their health and weight loss goals. The operation will help and force many patients to change their eating habits and lifestyles. Patients are not able to eat normally anymore. This can be a profound experience for many, being released from a prison of hunger. The success in keeping the weight off strongly relies on patient education and compliance with the rules. Failure to follow these guidelines can defeat the purpose of the bypass. The amount of weight that is lost will depend on how well the patient is using their tool or following the rules.
The rules are the key to success with all weight loss operations. Proper education and compliance with the rules are key to any patients long-term success. The operation to a significant degree will force many patients to help change their eating habits but we do not want patients to rely on that solely. The bypass is only a tool to help patients with the necessary work to reach their health and weight loss goals.
BENEFITS OF THE GASTRIC BYPASS OPERATION
The medical and emotional benefits of the gastric bypass operation begin almost immediately after surgery, and the cosmetic benefits follow their wake. Over time, the benefits of gastric bypass surgery may include:
- Significant sustained weight loss
- Blood sugar levels that become completely normal within one year of surgery
- Lower or normal blood pressure
- Lower or normal cholesterol levels
- Lower dosages of medications
- Relief from sleep apnea, acid reflux and urinary stress incontinence
- Less arthritis pain and improved mobility
- Increased energy and ability to exercise
- Improved mood and self-esteem
- Arrested progression of heart disease
- Improvement of many lung conditions
- Exercise endurance
- The co-morbidities of clinically severe obesity begin to resolve before complete weight loss even occurs. Patients can expect:
- Better control or cure of diabetes
- Lowered or normalized blood pressure and cholesterol
- Relief from sleep apnea, severe acid reflux, and urinary stress incontinence
- Eased lower back, knee and hip pain
- Enhanced mobility
- Arrested or slowed progression of evolving heart disease
Your need for medications will decrease while your medical problems improve. With the bypass, patients lose around 2/3 of their excess weight within one and a half years. The average weight loss is greater than 70% of excess weight. Half of that weight is lost in the first 6 months. In most patients, 80% are able to maintain their weight loss long-term. Some weight regain is common, approximately 10-15% after five years.
RISKS OF THE GASTRIC BYPASS OPERATION
As with all surgery, there are risks. Patients considering surgery must weigh the risks and benefits of surgery against the severity of their obesity. The decision to proceed is based on the premise that the treatment should be less harmful than the disease being treated. Please read the obesity disease section of our website to learn more about the disease, and the benefits weight loss surgery can offer to morbidly obese patients.
Complications can occur as with any type of surgery. Below is a list of some general and specific complications that are unique to the Roux-en-Y gastric bypass procedure:
- Perforation/injury of stomach/intestine
- Leakage from a connection or staple line causing infection
- Spleen injury (requiring removal) and/or other injury to organ(s)
- Gastric pouch outlet narrowing/stretching
- Small bowel obstruction
- Blood clots in legs
- Pulmonary embolism (blood clot in the lung)
- Inability to eat certain foods
- Development of gallstones or gallbladder disease
- Inflammation of pouch, pouch ulcer, marginal ulcer
- Dumping syndrome - intolerance to refined sugar, possibly fat
- Weight gain, failure to lose satisfactory weight
- Instrumentation failure may or may not result in additional surgery
- Pregnancy is not recommended during the first one and a half years of active weight loss
- Other potential complications:
- Anemia, vitamin/ mineral deficiency, protein malnutrition
Bypassing the duodenum can cause poor absorption of iron and calcium and result in 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 are already at risk for osteoporosis, particularly after menopause. 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 easily prevented and 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.
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 sweet 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. This is considered a beneficial side effect - it helps patients reduce sugar consumption.
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.
Operative mortality and morbidity: Operative (30-day) mortality for gastric bypass when performed by skilled surgeons is about 0.5%. Operative morbidity (e.g. pulmonary embolism, anastomotic leak, bleeding, wound infection) is about 5%. Compared with open procedures, the laparoscopic gastric bypass has a higher rate of intra-abdominal complications; whereas duration of hospitalization is shorter, wound complications are lower, and postoperative patient comfort is higher.
Long-term complications: gastric bypass can be associated with the dumping syndrome, stomal stenosis, marginal ulcers, staple line disruption, and internal hernias. Life-long oral or IM vitaminB12 supplementation, iron, vitamin B, folate, and calcium supplementation is recommended to avoid specific nutrient deficiency conditions, such as anemia. Ventral hernia formation is more prevalent after open gastric bypass than after the laparoscopic approach. A unique complication of gastric bypass is dilation of the bypassed distal stomach in the event of a small bowel obstruction, which can lead to rupture and death if not rapidly managed by distal gastric decompression.
Reversal and revision: gastric bypass can be functionally totally reversed, though this is rarely required. For all bariatric procedures, pure reversal without conversion to another bariatric procedure is almost certainly followed by a return to morbid obesity. A standard Roux-en-Y gastric bypass with failed weight loss can be revised to a very long-limb Roux-en-Y procedure.
Advantages
- Reliable and long-lasting weight loss
- Effective for remission of obesity-associated conditions
- Refined and standardized technique
Disadvantages
- Technically more complex when compared to sleeve gastrectomy or gastric band
- More vitamin and mineral deficiencies than sleeve gastrectomy or gastric banding
- There is a risk for small bowel complications and obstruction
- There is a risk of developing ulcers, especially with NSAID or tobacco use
- May cause “dumping syndrome”, a feeling of sickness after eating or drinking, especially sweets
- Requires adherence to dietary recommendations, life-long vitamin/mineral supplementation, and follow-up compliance
DECIDING ON THE ROUX-EN-Y GASTRIC BYPASS
The decision about which operation is best for you is a complicated one. The decision to proceed is based on the premise that the treatment should be less harmful than the disease being treated. Please read the obesity disease section of our website to learn about the obesity disease, and the benefits weight loss surgery can offer to morbidly obese patients. Although the information presented throughout our website may be helpful, you will be able to learn substantially more about the benefits and risks of the Bypass operation during your visit with our bariatric surgeons.
