Gastric Bypass Surgery / Roux-en-Y Surgery

What is a gastric bypass surgery and why is it necessary?
Gastric bypass procedures (GBP) are any of a group of similar operations used to treat morbid obesity – the severe accumulation of excess weight as fatty tissue – and the health problems (co-morbidities) it causes. Gastric bypass surgery, which is also known as stomach stapling makes the stomach smaller and allows food to bypass part of the small intestine. This makes you feel full more quickly than when your stomach was its original size, which reduces the amount of food you eat and thus the calories consumed. Bypassing part of the intestine also results in fewer calories being absorbed. This leads to weight loss, typically dramatic and markedly reduces co-morbidities.

Although guidelines vary, surgery is generally considered when your body mass index is 40 or higher or you have a life-threatening or disabling condition related to your weight. Your doctor may consider doing gastric bypass surgery if you have been unable to achieve satisfactory and sustained weight loss by dietary efforts, and are suffering from co-morbid conditions which are either life-threatening or are a serious impairment to the quality of life.

The following conditions may also be considered:
•    You have been obese for at least 5 years.
•    You do not have a history of alcohol abuse.
•    You do not have untreated depression or another major psychiatric disorder.
•    You are between 18 and 65 years of age.

Who is a candidate for gastric bypass surgery?
If you have a body mass index (BMI) of 40 or more you are considered severely obese, and therefore become a candidate for surgery.

Weight loss surgery may also be an option for people with a BMI between 35 and 40 who suffer from obesity-related problems (for example, severe sleep apnea, obesity-related heart disease, or diabetes). A person with a BMI of 30 or above is at a higher risk for certain diseases, including heart disease, high blood pressure, and coronary artery disease (CAD).

What are the different types of gastric bypass surgeries?
The variations of the gastric bypass surgery are:

•  Gastric bypass, Roux en-Y (proximal)
This is the most commonly performed gastric bypass technique. 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 (30 to 60 inches), 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 600 to 1000 cm (20 to 33 feet) 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 (40 to 60 inches) 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 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. It is claimed that construction of a long tubular gastric pouch reduces the risk of inflammatory complications, and renders it as safe as the Roux en-Y technique.


Details of Gastric Bypass Surgery

What do I need to do before the surgery?
Your surgeon will give you specific instructions on how to prepare for the procedure. You will be required not to eat or drink for many hours before your surgery. Your stomach must be completely empty to reduce the chances of vomiting during the procedure.

What happens on the day of the surgery?
Before your operation begins, an anesthesiologist will start an IV. You will then be taken to the operating room. After the appropriate form of anesthesia is administered, surgery will be performed.

What type of anesthesia will be used?
Gastric bypass surgery is performed under general anesthesia, which means you will be asleep during your surgery.

What happens during the surgery, and how is it performed?
There are two basic steps to the surgery:
Step 1 – The first step in the surgical procedure makes your stomach smaller. The surgeon divides the stomach into a small upper section and a larger bottom section using staples that are similar to stitches. The top section of the stomach (called the pouch) will hold your food.
Step 2 – After the stomach has been divided, the surgeon connects a section of the small intestine to the pouch. When you eat, the food will now travel from the pouch through this new connection (‘Roux limb’), bypassing the lower portion of the stomach. The surgeon will then reconnect the base of the Roux limb with the remaining portion of the small intestines from the bottom of the stomach, forming a Y-shape.

An increasing number of these operations are now performed by limited access or minimally invasive techniques called ‘laparoscopy’.

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 benefits of Laparoscopic Gastric Bypass, Roux-en-Y, include shortened hospital stay, reduced discomfort, shorter recovery time, less scarring, and minimal risk of incisional hernia.

What happens after the surgery?
Once the surgery is completed, you will be taken to a post-operative or recovery unit where a nurse will monitor your progress. You will be asked to walk the night of surgery. You will undergo a swallow study on the first postoperative day to make sure there are no problems. If there are no problems, you may be discharged on postoperative day two.

How long will I be in the hospital?
This surgery usually involves a 4 to 6 day hospital stay (2 to 3 days for a laparoscopic approach).

What are the risks associated with this procedure?
Some of the risks associated with the gastric bypass procedure are:
•    The connection between the stomach and the intestines may narrow (stomal stenosis) leading to nausea and vomiting after eating
•    The staples may pull loose
•    Hernia may develop
•    The bypassed stomach may enlarge, resulting in hiccups and bloating
•    Bleeding and infections
•    Follow-up surgeries to correct complications, or to remove excess skin
•    Gallstones due to significant weight loss in a short amount of time
•    Gastritis (inflammation of the lining of the stomach)
•    Dumping syndrome which occurs when food moves too quickly through the stomach and intestines causing nausea, weakness, sweating, faintness, and possibly diarrhea soon after eating
•    An iron and vitamin B12 deficiency which may lead to anemia
•    Calcium deficiency (if it occurs) can contribute to the development of early osteoporosis or other bone disorders
 
You are advised to discuss the possible risks and ways to avoid them with your surgeon prior to the surgery. Also, you may lessen the symptoms arising from nutritional deficiency by following your dietitian’s guidelines very carefully, especially during the first two months after surgery.

What should I watch out for?
You should call your doctor in case any of the following symptoms appear:
•    Fever
•    Worsening pain
•    Redness or swelling around the incision
•    The incision is warm to the touch
•    Drainage from the incision

Will there be scars?
The incisions should heal well, leaving small discrete scars.

When can I expect to return to work and/or resume normal activities?
Light activity at home is encouraged after surgery. Most people can return to their normal activities within 3 to 5 weeks.

What should I expect after the surgery?
You will be on a clear liquid diet for the first few days immediately following gastric bypass surgery, and then advance to a pureed diet. These foods must be very soft so they can pass easily through your new and smaller stomach. One of the main issues during this period will be adequate fluid intake, and dehydration can be a problem while you are recovering from the surgery. You will need to take in at least 32 ounces of liquid a day before leaving the hospital.

About one month after surgery you can expect to advance to a transitional diet. You will begin to eat more regular table foods, but may still go back to eating pureed foods if they are more easily tolerated. Once your diet begins to consist of more solid food, remember to chew each bite very slowly and thoroughly.

It will take some time for you to learn how to eat differently. This includes chewing carefully, learning to drink most liquids between meals rather than with meals, and learning that eating the wrong foods such as junk food or fatty foods can make you sick.

You will experience the most rapid weight loss in the first few months after surgery. Although you may lose close to 20 pounds a month, you also may experience a significant decrease in energy, as the amount of calories you are consuming is considerably less than what you were used to. You will need to be careful not to eat too much too quickly and side-effects such as diarrhea can be controlled by avoiding certain foods or by taking specific medications. Hair loss is also a symptom of rapid weight loss but usually begins to grow back within a few months.

Six months after the surgery you will probably be on a long-term maintenance diet, which is more or less what and how you will eat for the rest of your life. The maintenance diet for the most part consists of regular table foods, but in smaller portions. Most patients describe their meals as child sized, and often do not finish what they are served. You will grow accustomed to eating these smaller meals and most likely will be compensated by the ability to successfully control your weight.

You can expect to lose approximately 70% of your excess body weight during the first 2 years following surgery. Some patients will regain about 10% between the 2nd and 5th year after surgery, mostly because the stomach has slowly increased in size or because patients eventually learn to consume more calories without feeling sick.

Since gastric bypass patients take in less food and absorb less of what they take in, this makes them at risk for developing nutritional deficiencies. You must also make a life long commitment to taking vitamin, mineral and possibly protein supplements, and should carefully follow your dietitian’s guidelines.

Exercise and the support of others (for example, joining a support group with people who have undergone weight loss surgery) are extremely important to help you lose weight and maintain that loss following gastric bypass. You can generally resume exercise 6 weeks after the operation. Even sooner than that, you will be able to take short walks at a comfortable pace, with the approval and guidance of your doctor. Exercise improves your metabolism; while both exercise and attending a group support can boost your self-esteem and help you stay motivated.

The weight loss results of gastric bypass surgery are generally good. Most patients lose an average of 10 pounds per month and reach a stable weight between 18 and 24 months after surgery. Often, the greatest rate of weight loss occurs in the very beginning (that is, just following the surgery when you are still on a liquid diet).

The surgery is not a solution in and of itself. While it can train you to eat smaller quantities and feel full more quickly, you still have to do much of the work. To achieve weight loss and avoid complications from the procedure, you must exercise and eat properly – according to important, healthy guidelines that your doctor and nutritionist will teach you.

Cost and availability

How much does it cost?

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Which countries/hospitals is it available in?
Click here to check the availability of gastric bypass surgery with our partner hospitals.

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Note: All information presented here has been obtained from publicly available medical resources and is here for reference purposes only. Healthbase does not claim to be a medical professional and does not provide any advice on any issues relating to medical treatment.