Roux-En-Y Gastric Bypass Guide

What Is Roux-en-Y?

Roux-en-Y Gastric Bypass (RYGB) – named after the French surgeon (Roux) who devised it and the Y-shape created by the roux-limb as it joins the small intestine – is another bariatric procedure endorsed by the NIH Consensus Report on surgical treatment of severe clinical obesity. Roux-en-Y is currently the most commonly performed bariatric operation in the United States, and roughly 7 out of 10 bariatric surgeons use it as their primary weight loss procedure. An easier gastric bypass operation than either Biliopancreatic Diversion Stomach Bypass, or Duodenal Switch Stomach Bypass, Roux-en-Y has been practiced for more than 30 years, during which it has demonstrated a high long-term success rate with relatively low rates of mortality (less than one percent) and post-operative health complications. Roux-en-Y patients typically lose 50-75 percent of their initial excess weight, which is a sufficient weight reduction to cure or significantly reduce most of the life threatening medical conditions associated with severe clinical obesity.

How Does Roux-en-Y Bypass Work?

The physiological rationale behind Roux-en-Y obesity surgery is the same as for all stomach bypass surgeries. A bypass is designed to reduce the quantity of food which patients can eat (the restrictive part of the procedure), and second, to reduce the amount of nutrients and calories which can be absorbed from this reduced food-intake (the malabsorptive part of the procedure). To appreciate how the restriction element works, remember that a normal stomach can stretch to over 1000 ml. During the Roux operation, the surgeon creates a smaller stomach (15-30 ml in size) – dramatically reducing the amount of food which can be accomodated. The malabsorption element is not concerned with food intake, which is determined by the esophagus and stomach, but with how much of the ingested food is actually absorbed by the body. Here, it’s important to remember that most nutrient and caloric absorption occurs as the food passes along the small intestine. In simple terms, the longer the functional length of the small bowel, the more absorption can take place. So, during Roux-en-Y surgery, the surgeon aims to bypass a significant section of this gastrointestinal tract thus reducing the patient’s uptake of both nutrients and calories. The combination of less food consumed and fewer calories absorbed is what makes Roux-en-Y bypass such an effective weight loss treatment.

During a Roux-en-Y gastric bypass, the surgeon creates a small stomach pouch (15-30 ml in volume) at the upper part of the stomach either by using surgical staples or a gastric band. The site for the small pouch is usually sited in a section of the stomach which is least likely to stretch. The stomach pouch is totally separated from the rest of the stomach and instead is connected directly to the middle portion of the small intestine (jejunum), bypassing the lower part of the stomach and the early segment of the small intestine (duodenum). The tube connecting the pouch to the jejunum is called the “roux limb” or “food channel”. Meanwhile, gastric juices from the stomach and digestive enzymes from the pancreas, and bile, continue to flow from the lower part of the stomach and duodenum down the small intestine which is referred to as the “alimentary channel”. These two channels meet at a Y-shaped junction – which gives the procedure its name – and together form a common channel where absorption of nutrients and calories begins.What Happens During A Roux-en-Y Operation?

There are two basic variants of the Roux-en-Y gastric bypass procedure: a proximal roux-en-Y, in which Y-intersection occurs at the upper or proximal part of the small intestine, and a distal roux-en-Y in which the Y-intersection is joined to the lower or distal part of the small intestine. The proximal roux variant allows for greater absorption of nutrients, while the distal variant provides less absorption of food – mainly of fats and starches, but also of various minerals and fat-soluble vitamins – but greater weight loss. In both cases, the roux-en-Y patient experiences a very rapid feeling of fullness in the stomach, followed by a feeling of growing satiety after starting to eat.

What Happens To The Unabsorbed Food After Roux-en-Y Bypass?

Unabsorbed fats and starches which the body has not had time to digest, pass out of the small bowel into the large intestine, where bacterial action produces irritants and malodorous gases. These bowel discomforts together with the risk of nutritional deficiency are standard side-effects in stomach bypass surgery, which must be balanced against the significant health benefits of weight loss achieved.

Can Roux-en-Y Bypass Be Performed Laparoscopically?

Yes. The roux-en-Y gastric bypass operation can be performed either laparoscopically, via five very small incisions in the abdominal wall, or by the open surgical method, via a traditional midline abdominal incision. Many roux surgeons now prefer the laparoscopic approach due to reduced pain, faster recovery and a lower incidence of incision-related complications like infection or hernia.

What Weight Loss Results From Roux-en-Y Gastric Bypass?

Typically, roux patients lose roughly 70 percent of their initial excess body weight during the first 24 months after surgery. Occasionally, patients experience a weight regain of about 10 percent between years 2 and 5. Bariatric experts attribute this to two factors. First, the functional capacity of the small pouch increases in volume to accomodate more food. Second, roux patients learn how to take in extra calories without incurring symptoms of dumping syndrome and making themselves sick. This second factor can only be corrected by greater patient compliance with post-op dietary guidelines brought about by greater post-op counseling and support services.

What Happens After Roux-en-Y Surgery?

On average, the roux patient typically leaves hospital 2-4 days after surgery, depending on whether the operation was performed by laparoscope or open surgery. Resumption of most normal activities typically takes place 7-14 days after surgery, again depending on the surgical method used. In the absence of any health complications, the first post-op follow-up is scheduled for 1 week after the operation. Much depends on the health condition and strength of the patient.

What Do Patients Eat After Roux-en-Y Gastric Bypass Surgery?

For the first few days patients follow a clear liquid diet, advancing to a pureed diet. These semi-solid foods will be very soft, to ensure problem-free passage through the small, newly formed pouch and stoma. An important health issue at this time is the risk of dehydration, so adequate fluid intake is vital. About 30 days after roux-en-y surgery, patients move on to a transitional diet. They may start eating more regular table foods, but frequently revert to easily tolerated pureed foods. They learn how to chew food carefully, learn to drink liquids between meals rather than with them, and learn that eating the wrong foods, such as sweets or fatty foods, can cause nausea and vomiting. Typically, about six months after their stomach bypass surgery, patients are following a long-term maintenance diet, which is pretty much how they will eat for the rest of their lives. This long-term maintenance diet mostly comprises regular table foods, but in small or “child-size” portions.

What Is The Main Health Benefit Of Roux-en-Y Gastric Bypass?

The main advantage of roux-en-Y bariatric surgery is a good rate of weight loss in most patients. Roux patients typically lose 50-75 percent of their initial excess weight (above ideal weight), compared to 60-80 percent for duodenal switch bypass and 40-60 percent for Lap-Band patients. This weight loss is enough to significantly improve their weight-related health problems.

What Is The Main Health Problem Associated With Roux-en-Y Gastric Bypass?

The main health danger of any bypass surgery is the operation itself. As a major medical procedure performed under general anesthetic, it carries a range of serious health risks. Aside from this, probably the most common health problem experienced by roux patients is nutritional deficiency. The RYGBP operation causes food to bypass the gastric fundus, body, antrum, all the duodenum and most/all of the proximal jejunum. As a result, patients are at risk of developing iron deficiency, vitamin B12 deficiency, as well as inadequate intake of vitamin D and calcium. Because of this, life long supplements of multivitamins, vitamin B12 iron and calcium are mandatory in order to maintain a healthy intake of vitamins and minerals.

What Are The Adverse Health Effects Of Roux Gastric Bypass?

Health complications after roux bypass are not uncommon, but the severity is lower than after many other bariatric procedures. Health dangers and side-effects of roux-en-Y bypass may include: premature death, anastamotic leakage, anastamotic stricture, nutritional deficiencies, problems with gastric staples, dumping syndrome, diarrhea and temporary hair loss. All these post-op health complications must be balanced against the known risks of morbid or super-obesity, which the roux gastric bypass helps to alleviate or cure.