Roux-En-Y Gastric Bypass surgery makes the stomach smaller and causes food to bypass part of the small intestine. You will feel full more quickly than when your stomach was its original size. This reduces the amount of food you can eat at one time. Bypassing part of the intestine reduces how much food and nutrients are absorbed. This leads to weight loss.
Gastric bypass procedures are group of similar operations that first divides the stomach into a small upper pouch and a much larger lower “remnant” pouch and then re-arranges the small intestine to allow both pouches to stay connected to it. Surgeons have developed several techniques to reconnect the intestine, thus leading to several different Gastric Bypass names. Any Gastric Bypass procedures leads to a marked reduction in the functional volume of the stomach, accompanied by an altered physiological and physical response to food.
The operation is prescribed to treat morbid obesity, defined as a BMI greater than 40, and also to treat type 2 diabetes, hypertension, sleep apnea and other co-morbid conditions. However it is decided on a case-by-case basis after reviewing your personal history. Bariatric surgery is the term encompassing all of the surgical treatments for morbid obesity, not just gastric bypasses, which make up only one class of such operations. The resulting weight loss, typically dramatic, markedly reduces co-morbidities.
Weight Loss Alternative Options
Though it’s the most commonly used, gastric bypass is just one kind of weight-loss surgery. Other types include:
Adjustable gastric banding:
The surgeon uses an inflatable band to partition the stomach into two parts. He or she then wraps the band around the upper part of your stomach and pulls it tight, like a belt, creating a tiny channel between the two pouches. The band keeps the opening from expanding and is designed to stay in place indefinitely. But it can be adjusted or surgically removed if necessary. Most surgeons perform this operation using a laparoscope.
Vertical banded gastroplasty:
This operation divides the stomach into two parts — limiting space for food and forcing you to eat less. There is no bypass. Using a surgical stapler, the surgeon divides your stomach into upper and lower sections. The upper pouch is small and empties into the lower pouch — the rest of your stomach. Partly because it doesn’t lead to adequate long-term weight loss, surgeons use it less commonly than gastric bypass.
In this procedure, a portion of your stomach is removed. The remaining pouch is connected directly to your small intestine, but completely bypasses your duodenum and jejunum where most nutrient absorption takes place. This weight-loss surgery offers sustained weight loss, but it presents a greater risk of malnutrition and vitamin deficiencies and requires close monitoring.
Candidates for Gastric Bypass
In order to be considered a candidate for gastric bypass surgery, an individual must meet certain set requirements. You may qualify for this body contouring procedure if you have a:
- Body Mass Index (BMI) of 40 for higher (extreme obesity)
- BMI of 35 to 39.9 (obesity), and dealing with a serious weigh-related health problem (diabetes, high blood pressure, etc.)
The following are also key factors that surgeons evaluate in patients who are seeking the gastric bypass procedure:
- Risk factors for other medical conditions and diseases
- Waist circumference
- Psychological state
Body mass index (BMI) is a measure of body fat based on height and weight that applies to both adult men and women.
- Underweight = <18.5
- Normal weight = 18.5-24.9
- Overweight = 25-29.9
- Obesity = BMI of 30+
Generally, gastric bypass surgery is reserved for people who are unable to achieve or maintain a healthy weight through diet and exercise, are severely overweight, and who have health problems as a result. Gastric bypass may be considered if:
Your body mass index (BMI) is 40 or higher (extreme obesity).
Your BMI is 35 to 39.9 (obesity), and you have a serious weight-related health problems such as diabetes or high blood pressure.
Once the surgeon fully assesses the patient, the best-suited technique will be discussed before a personalized surgical plan is developed.
Preparing for Gastric Bypass
Surgical candidates go through an extensive screening process. Not everyone who meets the criteria for gastric bypass is psychologically or medically ready for the surgical procedure. A team of professionals, including a physician, dietitian, psychologist and surgeon, evaluate whether the surgery is appropriate for you. This involves identifying which aspects of your health would be expected to improve after surgery and what aspects of your health may increase the risks of surgery. Surgery is recommended when the perceived benefits of surgery outweigh the recognized risks.
Medical Evaluation for Gastric Bypass
A team of health professionals — usually including a doctor, dietitian, psychologist and surgeon — will evaluate whether gastric bypass surgery is appropriate for you. The evaluation essentially determines if the health benefits outweigh the potentially serious risks of this major procedure. Even if you meet the criteria for gastric bypass surgery, you will still need to be evaluated to see if you’re psychologically and medically ready to undergo the procedure.
Your Nutrition and Weight History
The team reviews your weight trends, diet attempts, eating habits, exercise regimen, stress level, time constraints, motivation and other factors.
Your Medical Condition
Some health problems increase the risks associated with having surgery or may be worsened by surgery, such as blood clots, liver disease, heart problems, kidney stones and nutritional deficiencies. The team will evaluate what medications you take, how much alcohol you drink and whether you smoke. You also will have a thorough physical exam and laboratory testing.
Your Psychological Status
Certain mental health conditions may contribute to obesity or make it more difficult for you to maintain the health benefits of gastric bypass surgery. These may include binge-eating disorder, substance abuse, depression, anxiety disorders and issues related to childhood sexual abuse. While these may not prevent you from having gastric bypass surgery, your doctors may want to postpone surgery to ensure that any condition is appropriately treated and managed.
The team will also assess your willingness and ability to follow through with recommendations made by your health care team and to carry out prescribed changes in your diet and exercise routine.
Although there’s no specific age limit for gastric bypass surgery, the risks increase if you’re over age 65. The surgery remains controversial in people under age 18.
Before Gastric Bypass Procedures
Before a gastric bypass surgery, patients need to make several changes to their lifestyle. Doctors may recommend smaller meal portions and restrict some foods. Doctors may also encourage smokers to quit or to reduce the number of cigarettes they smoke. Smokers should quit at least two weeks before surgery, but six to eight weeks prior to surgery is ideal. Quitting smoking is important because smokers heal more slowly than nonsmokers, which can result in complications after the surgery, including infection. In addition, smokers are at a higher risk for breathing problems while under anesthesia.
Patients receive antibiotics before the surgery and often up to 24 hours after the surgery in an effort to minimize the chance for infection. A common complication of any hospital patient that is lying in bed for long periods of time is DVT, or deep vein thrombosis. The inactivity of the legs allows blood clots to form, which can then travel throughout the body and possibly result in a stroke or a pulmonary embolism. In order to prevent this, doctors usually prescribe a pre-operation regimen of compression stockings along with a drug that thins the blood and keeps blood clots from forming. As soon as six hours after surgery, a patient should begin walking around in order to prevent DVT.
Gastric Bypass Surgery Overview
The stomach is located in the upper abdomen, under the lower ribs. When you swallow food, it moves from your mouth to your esophagus and ultimately lands in the sac-shaped stomach. There, strong stomach acids begin the digestive process. It takes nearly three hours for the food to liquefy and then move into the first section of your small intestine, known as the duodenum. In this section, pancreatic juices and bile speed digestion and the majority of the body’s nourishment and calories are absorbed. Food is then moved to the middle section of the small intestine, the jejunum, then on to the final section of the small intestine, the ileum. In these sections, the absorption of calories and nutrients take place on a smaller scale. From the small intestine, any undigested food is passed to the large intestine, where it remains until it is eliminated.
Gastric bypass surgery works by altering this digestive process in two ways. It decreases the size of the stomach and causes food to bypass part of the small intestine. These two steps result in the patient feeling fuller more quickly and absorbing fewer calories.
The two gastric bypass surgeries currently in use are the Roux-en-Y gastric bypass and the extensive gastric bypass, or biliopancreatic diversion. The latter of these two surgeries can help a patient lose weight, but it carries of high risk of nutritional deficiencies and a higher risk of death than Roux-en-Y surgery. For this reason, surgeons don’t use it as often as they use the Roux-en-Y bypass, which is the most common gastric bypass surgery in the United States.
The Roux-en-Y gastric bypass derives its name from the rearrangement of the small intestines into a Y-shaped configuration. One part of this Y-shape is referred to as a Roux limb. It moves food from the new upper stomach pouch into the small intestine, thus bypassing the lower stomach, the duodenum, and the first portion of the jejunum in order to reduce absorption.
Laparosocpic Bariatric Surgery
Laparoscopic surgery is performed using several small incisions, or ports, one of which conveys a surgical telescope connected to a video camera, and others permit access of specialized operating instruments. The surgeon actually views his operation on a video screen. The method is also called limited access surgery, reflecting both the limitation on handling and feeling tissues, and also the limited resolution and two-dimensionality of the video image. With experience, a skilled laparoscopic surgeon can perform most procedures as expeditiously as with an open incision—with the option of using an incision should the need arise.
The Laparoscopic Gastric Bypass, Roux-en-Y, first performed in 1993, is regarded as one of the most difficult procedures to perform by limited access techniques, but use of this method has greatly popularized the operation, with benefits which include shortened hospital stay, reduced discomfort, shorter recovery time, less scarring, and minimal risk of incisional hernia.
Gastric Bypass Procedure Consists of:
Creation of a small, (15–30 mL/1–2 tbsp) thumb-sized pouch from the upper stomach, accompanied by bypass of the remaining stomach (about 400 mL and variable). This restricts the volume of food which can be eaten. The stomach may simply be partitioned (typically by the use of surgical staples), or it may be totally divided into two parts (also with staplers). Total division is usually advocated, to reduce the possibility that the two parts of the stomach will heal back together (“fistulize”), negating the operation.
Re-construction of the GI tract to enable drainage of both segments of the stomach. The technique of this reconstruction produces several variants of the operation, which differ in the lengths of small bowel used, the degree to which food absorption is affected, and the likelihood of adverse nutritional effects.
Variations of the Gastric Bypass Techniques
Gastric bypass, Roux en-Y (proximal)
This variant is the most commonly employed gastric bypass technique, and is by far the most commonly performed bariatric procedure in the United States. It is the operation which is least likely to result in nutritional difficulties. The small bowel is divided about 45 cm (18 in) below the lower stomach outlet, and is re-arranged into a Y-configuration, to enable outflow of food from the small upper stomach pouch, via a “Roux limb”. In the proximal version, the Y-intersection is formed near the upper (proximal) end of the small bowel. The Roux limb is constructed with a length of 80 to 150 cm (31 to 59 in), preserving most of the small bowel for absorption of nutrients. The patient experiences very rapid onset of a sense of stomach-fullness, followed by a feeling of growing satiety, or “indifference” to food, shortly after the start of a meal.
Gastric bypass, Roux en-Y (distal)
The normal small bowel is 6 to 10 m (20 to 33 ft) in length. As the Y-connection is moved farther down the Gastrointestinal tract, the amount of bowel capable of fully absorbing nutrients is progressively reduced, in pursuit of greater effectiveness of the operation. The Y-connection is formed much closer to the lower (distal) end of the small bowel, usually 100 to 150 cm (39 to 59 in) from the lower end of the bowel, causing reduced absorption (mal-absorption) of food, primarily of fats and starches, but also of various minerals, and the fat-soluble vitamins. The unabsorbed fats and starches pass into the large intestine, where bacterial actions may act on them to produce irritants and malodorous gases. These increasing nutritional effects are traded for a relatively modest increase in total weight loss.
Loop Gastric bypass (“Mini-gastric bypass”)
The first use of the gastric bypass, in 1967, used a loop of small bowel for re-construction, rather than a Y-construction as is prevalent today. Although simpler to create, this approach allowed bile and pancreatic enzymes from the small bowel to enter the esophagus, sometimes causing severe inflammation and ulcerationyes either the stomach or the lower esophagus. If a leak into the abdomen occurs, this corrosive fluid can cause severe consequences. Numerous studies show the loop reconstruction (Billroth II gastrojejunostomy) works more safely when placed low on the stomach, but can be a disaster when placed adjacent to the esophagus. Thus even today thousands of “loops” are used for general surgical procedures such as ulcer surgery, stomach cancer and injury to the stomach, but bariatric surgeons abandoned use of the construction in the 1970s, when it was recognized that its risk is not justified for weight management.
The Mini-Gastric Bypass, which uses the loop reconstruction, has been suggested as an alternative to the Roux en-Y procedure, due to the simplicity of its construction, which reduced the challenge of laparoscopic surgery.
The Roux en-Y Procedure
This surgery is performed under general anesthesia and takes approximately four hours. In the first step of the procedure, the surgeon decreases the size of the stomach, which is normally the size of a football, to the size of an egg. To do this, the surgeon staples the stomach together, leaving only a small pouch at the top. He then cuts the small intestine at the jejunum and attaches it to the newly formed stomach pouch. This Roux limb ensures that food will bypass the remaining part of the stomach and the first part of the small intestine.
The section of the small intestine still attached to the lower part of the stomach — the duodenum — is then reattached to the middle section of the small intestine, creating a Y-formation just below the stomach. This reattachment allows the stomach to stay healthy enough to continue secretion of digestive juices, which are carried to the midsection of the small intestine to aid in digestion.
These steps make people who have had gastric bypass surgeries feel full sooner, so they don’t consume as many calories. They also absorb fewer calories through the small intestine. Patients then burn more calories than they absorb and lose weight as a result.
When surgeons first started performing gastric bypass surgeries, they began by making a large incision in the abdomen. Now, many surgeons perform gastric bypass surgeries through a very small incision. The surgeon inserts a narrow tool called a laparoscope into the incision. The surgeon can guide a tiny camera through this tube to see what is going on inside the abdomen. Doctors and patients often prefer this laparoscopic technique due to its faster recovery rate and decreased risk factors.
During the procedure, patients also have a tube inserted into their nose and passed down to the new, smaller stomach pouch. The tube connects to a suction device that keeps the pouch empty, helping it heal correctly. This surgery is usually completed in about four hours, and most patients stay in the hospital for two to six days to be monitored for any complications.
Gastric Bypass Weightloss Results
In addition to dramatic weight loss, gastric bypass surgery may improve or resolve the following conditions associated with obesity:
- Type 2 diabetes
- High blood cholesterol
- High blood pressure
- Obstructive sleep apnea
- Gastroesophageal reflux disease (GERD)
The improvements observed in type 2 diabetes, high blood pressure and high blood cholesterol may significantly decrease the risk of cardiovascular events in individuals who have undergone gastric bypass surgery compared with those treated through other means. Gastric bypass surgery has also shown to improve mobility and quality of life for people who are severely overweight.
IMPORTANT: Surgery for weight reduction isn’t a miracle procedure. It doesn’t guarantee that you’ll lose all of your excess weight or that you’ll keep it off long term. Weight-loss success after gastric bypass surgery depends on your commitment to making lifelong changes in your eating and exercise habits. But the feeling of accomplishment as you lose weight and your improved health are significant benefits and are well worth your efforts.
Recovery Bariatric Surgery
Gastric bypass surgery is performed under a general anesthesia. This means you inhale analgesics as a gas or receive them through an intravenous (IV) line so that you’re asleep during the surgery.
During surgery, a tube is passed through your nose into the upper stomach pouch. Occasionally, this tube stays in overnight. The tube is connected to a suction machine after surgery to keep the small stomach pouch empty so that the staple line can heal.
You may have another tube in the bypassed stomach. This tube would come out of the side of your abdomen and is removed four to six weeks after surgery. Some skin irritation may develop around this tube.
Gastric bypass surgery takes about 90 minutes. After surgery, you wake up in a recovery room, where medical staff monitor you for any complications. Your hospital stay may last from three to five days.
You won’t be allowed to eat for one to two days after the surgery so that your stomach can heal. Then, you’ll follow a specific dietary progression for about 12 weeks. This begins with liquids only, proceeds to pureed and soft foods, and finally to regular foods.
With your stomach pouch reduced to the size of a walnut, you’ll need to eat very small meals throughout the day. In the first six months after surgery, eating too much or too fast may cause vomiting or an intense pain under your breastbone. The amount you can eat gradually increases, but you won’t ever be able to return to your old eating habits.
You may experience one or more of the following changes as your body reacts to the rapid weight loss in the first three to six months:
- Body aches
- Feeling tired, as if you have the flu
- Feeling cold
- Dry skin
- Hair thinning and hair loss
- Mood changes
Within the first two years of surgery, you can expect to lose 50 percent to 60 percent of your excess weight. If you closely follow dietary and exercise recommendations, you can keep most of that weight off long-term.
Gastric Bypass Post Operative Care
The post-op diet is a crucial part of your healing process. It is important to strictly follow these diets to ensure success following your surgery but also to maintain good nourishment. There are several phases involved that will take you from day one to the end with 3 to 5 solid meals per day. Exercise and lab work are equally important and should be taken seriously.
Diet After Gastric Bypass Surgery
PHASES 1 & 2: A clear liquid meal program is usually initiated within 24 hours after any of the bariatric procedures. This should be continued for 21 straight days. Clear liquids include fruit juices, broth, Gatorade, popsicles, and tea. Full liquids include drinkable yogurts, meal replacements, and soups.
PHASE 3: In the next phase you move to soft food, as tolerated, at about 60g of protein per day. Soft foods include eggs, ground meats, poultry, soft moist fish, cooked beans, low-fat cottage cheese, well-cooked vegetables and soft or peeled fruit. Always eat protein first and avoid rice, bread and pasta .
PHASE 4: The final phase involves following a healthy, balanced diet consisting of adequate protein, fruits, vegetables, and grains. Eat from small plates and use small utensils to help control portions. Calorie counts need to be based on height, weight, and age. Chew thoroughly and do not eat and drink at the same time (more than 30 minutes apart). Adhere to a balanced meal plan that consists of more than five servings of fruits and vegetables daily for optimal fiber consumption, colonic function, and phytochemical consumption. Protein intake should average 60-120g daily. Avoid liquid calories.
Supplements After Gastric Bypass
Because a gastric bypass is a restrictive and mal-absorption procedure you will require daily supplements. These include complete chewable or liquid multivitamins with iron twice a day, chewable calcium citrate (2000 mg) with vitamin (take separately from MVI with iron), and vitamin B12 (300 mcg sublingual) daily.
Exercise After Bariatric Weight Loss Sugery
Exercise may be the most important factor that can help a patient experience long-standing and successful weight loss.
Regimen: Start walking from Day 1. Increase your walking each day. Add other aerobic exercises like swimming and bicycle riding as your surgeon permits and as you feel so inclined. Start light weight training and sit-ups as your surgeon allows. Increase weights and number of reps gradually. This type of exercise will increase muscles mass which improves strength, increases bone density, and increases metabolism. Consider using a personal trainer for education about exercise, motivation, and proper routines. Drink plenty of water before, during, and after exercise.
Gastric Bypass Post-op Tests
As part of your follow up, biochemical measures are important to ensure the wellness of your health. In the first year, post-surgery, you should have lab work done in the following areas every 3-6 months and annually after that.
- CBC, platelets
- Iron studies/Ferritin
- Vitamin B12
- Liver Function
- Lipid Profile
- 25-Hydroxy vitamin D
Possible Gastric Bypass Risks
As with any major surgery, gastric bypass carries risks such as bleeding, infection and an adverse reaction to the anesthesia. Possible risks specific to this surgery include:
- Death. A risk of death has been associated with gastric bypass surgery. The risk varies depending on age, general health and other medical conditions. Talk to your doctor about the exact level of risk gastric bypass surgery may pose for you.
- Blood clots in the legs. Blood clots in the legs are more likely to occur in very overweight people. Blood clots can be dangerous. In some cases, they travel to the lungs and lodge in the lungs’ arteries causing a pulmonary embolism — a serious condition that damages lung tissue and can lead to death. Walking and using leg wraps that apply intermittent pressure to the leg can help reduce this risk of blood clots in the legs.
- Leaking at one of the staple lines in the stomach. This severe postoperative problem would be treated with antibiotics. Most cases heal with time. Sometimes, the leak can be serious enough to require emergency surgery.
- Pneumonia. Excess weight places extra stress on the chest cavity and lungs. This means a higher risk of developing pneumonia after the surgery.
- Narrowing of the opening between the stomach and small intestine. This rare complication may require either an outpatient procedure to pass a tube through your mouth to widen (dilate) the narrowed opening or corrective surgery.
Gastric bypass can also cause dumping syndrome, a condition where stomach contents move too quickly through the small intestine causing nausea, vomiting, diarrhea, dizziness and sweating. Other common complications of gastric bypass surgery include:
- Vitamin and mineral deficiency
- Bleeding stomach ulcer
- Hernia at the incision site
- Intolerance to certain foods