About Roux-en-Y

Memorial Health Bariatrics performs the Roux-en-Y gastric bypass procedure. According to the American Society for Bariatric Surgery and the National Institutes of Health, Roux-en-Y gastric bypass is the current gold standard procedure for weight loss surgery. It is one of the most frequently performed weight loss procedures in the United States.

In this procedure, the surgeon uses a stapling device to create a small (30 cc) stomach pouch. The remainder of the stomach is not removed, but is completely separated from the pouch.

The outlet from this newly formed pouch empties directly into the lower portion of the jejunum (the middle section of the small intestine), bypassing 75 to 100 cm of small intestine. This is done by dividing the small intestine just beyond the duodenum (first part of the small intestine) for the purpose of bringing it up and constructing a connection with the newly formed stomach pouch. The other end is connected into the side of the Roux limb of the intestine creating the "Y" shape 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.

This procedure is both restrictive and malabsorptive. In recent years, better clinical understanding of procedures combining restrictive and malabsorptive approaches has increased the choices of effective weight loss surgery for thousands of patients. By adding malabsorption, food is delayed in mixing with bile and pancreatic juices that aid in the absorption of nutrients. The result is an early sense of fullness, combined with a sense of satisfaction that reduces the desire to eat.

The average excess weight loss after the Roux-en-Y procedure is higher in patients who comply with the diet and exercise programs prescribed after surgery. One year after surgery, weight loss can average 77 percent of excess body weight.

Studies show that after 10 to 14 years, 50 to 60 percent of excess body weight loss has been maintained by some patients.

Laparoscopic Roux-en-Y Gastric Bypass

In most patients, Roux-en-Y can be performed laparoscopically. When a laparoscopic operation is performed, a small video camera is inserted into the abdomen. The surgeon views the procedure on a separate video monitor. Most laparoscopic surgeons believe this gives them better visualization and access to key anatomical structures.

The camera and surgical instruments are inserted through small incisions made in the abdominal wall. This approach is less invasive because it replaces the need for one long incision to open the abdomen. A recent study shows that patients having had laparoscopic weight loss surgery experience less pain after surgery resulting in easier breathing and lung function and higher overall oxygen levels. Other realized benefits with laparoscopy have been fewer wound complications such as infection or hernia, and patients returning more quickly to pre-surgical levels of activity.

Laparoscopic procedures for weight loss surgery employ the same internal technique as their "open" counterparts and produce similar excess weight loss. Not all patients are candidates for this approach.

Risks of Roux-en-Y

It is important to remember that there are no ironclad guarantees in any kind of medicine or surgery. There can be unexpected outcomes in even the simplest procedures. The Roux-en-Y gastric bypass procedure carries significant risks, including the possibility of death. Additional risks are listed below.

In this procedure the stomach size is substantially reduced. This reduction lowers the production of stomach acid that is important in the absorption of iron and calcium. As a result, poor absorption of iron and calcium can result in the 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, already at risk for osteoporosis that can occur after menopause, should be aware of the potential for heightened bone calcium loss due to poor absorption of dietary calcium.

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 can be managed through proper diet and vitamin supplements.

Because the food bypasses the duodenum, a chronic anemia due to Vitamin B12 deficiency may occur. The problem can usually be managed with Vitamin B12 pills or injections. In addition, absorption of thiamine (vitamin B1) is also altered. Lack of this vitamin causes confusion and nerve damage to nerves of the leg. This problem is avoided by taking your vitamin supplements.

A condition known as "dumping syndrome" can occur as the result of rapid emptying of stomach contents into the small intestine. This is triggered when too much sugar or large amounts of 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 diarrhea after eating. Some patients are unable to eat any form of sweets after surgery.

The effectiveness of the procedure may be reduced if the stomach pouch is stretched. This can occur by overeating. In addition, once carbohydrates are restarted at about six months, patients can begin to regain weight. This is avoided by carefully following the nutrition program.

The majority 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 disease should occur. Treatment of these conditions if they occur may require further surgery.

Patients who undergo gastric bypass are at increased risk to develop blood clots in their legs that can travel to their lungs. Early walking, the use of compression boots, anti-embolism stockings, and small doses of blood thinning agents help lower this risk.

Other Post-Surgery Issues

Patients who undergo bariatric surgery must make a lifelong commitment to eat healthy, exercise, and adhere to strict dietary guidelines. The lifestyle changes can seem overwhelming at first and can strain relationships within families and between married couples. To help patients achieve their goals and deal with the changes surgery and weight loss can bring, Memorial Health Bariatrics offers support groups, counseling, and continuing education.

Ultimately, the decision to have the procedure is entirely up to you. After having heard all the information, you must decide if the benefits outweigh the side effects and potential complications.

This surgery is only a tool. Your ultimate success depends on strict adherence to the recommended dietary, exercise, and lifestyle changes.

After Roux-en-Y

After bariatric surgery, you will spend three to four days at Memorial Health University Medical Center. You will begin doing simple exercises from your bed just four hours after surgery. You will have some discomfort after surgery and will receive pain relief as needed.

To help prevent blood clots, anti-embolism stockings and sequential compression boots will be placed on your legs. You will also receive small doses of a blood thinning agent to prevent clot formation. We will encourage you to get out of bed and walk several times a day.

Initially, you will only be allowed to consume liquids. In the weeks following surgery, you will begin to eat small portions of solid food again. For approximately six months, you will be on a strict low-carb, protein diet.

Follow-Up

You will return to Memorial Health Bariatrics after two weeks, one month, three months, six months, one year, and then annually for the rest of your life. At each of these visits, we will check your weight, measure certain parts of your body, check your strength, and perform other tests as needed. These check-ups are necessary to help us ensure that you are healthy and are following your diet and exercise guidelines. Taking special vitamins is a critical part of your postoperative care.

Support

You will be asked to attend a support group regularly. Research has shown that adequate support is a vital part of weight loss success. We offer meetings in Savannah in the Mercer Auditorium located in the Hoskins Center on the Memorial Health campus. We also hold monthly meetings in outlying communities.

You will meet with an exercise physiologist and dietitian. You will be given telephone access to a nurse 24 hours a day, seven days a week. Additional counseling will be available if necessary.

Changing the Way You Eat

The modifications made to your gastrointestinal tract will require permanent changes in your eating habits. Some of the changes include:

  • It is essential that you chew your food thoroughly. You will not be able to eat steak or other chunks of meat if they are not ground or chewed thoroughly.
  • You are not to drink fluids while eating. You need to wait 90 minutes after eating before drinking any fluid.
  • Omit desserts and other items with sugar listed as one of the first three ingredients.
  • Omit carbonated drinks, high-calorie nutritional supplements, milk shakes, high-fat foods, and foods with high fiber content.
  • Avoid alcohol.
  • Limit snacking between meals.
  • Take vitamin supplements as directed by your doctor.

Returning to Work

Your ability to resume pre-surgery levels of activity will vary based on your physical condition and the nature of the activity. Many patients return to full pre-surgery levels of activity within six weeks of their procedure. Patients who have had a minimally invasive laparoscopic procedure may be able to return to these activities within a few weeks.

Birth Control and Pregnancy

It is strongly advised that women of childbearing age use at least two effective forms of birth control during the first 16 to 24 months after weight loss surgery. A woman's ability to become pregnant returns within a week or two after you start to lose weight. The added demands pregnancy places on your body and the potential for fetal damage make this requirement very important.