Overview of Roux-en-Y Gastric Bypass
The worldwide issue of obesity has become a significant health problem. The World Health Organization measures obesity using a system called body mass index (BMI), which is a number calculated using a person’s weight and height. If your BMI ranges from 18.5 to 24.9, you’re considered within the normal weight range. If it’s 25 to 25.9, you would be considered overweight, while a BMI of 30 and above is classified as obese. When a person’s BMI is greater than 50, this is called “super-obesity,” and when it’s greater than 60, it’s referred to as “super-super obesity”.
Current research unveiled that over 1 billion adults and children worldwide are now considered obese. The rate of obesity has quadrupled among children and teenagers and more than doubled among adults between 1990 and 2022.
Various studies have shown that being obese is linked to a higher risk of death. Particularly, people aged 50 years or older, and nonsmokers with higher BMI often face a higher risk. Obesity can also cause a number of serious health problems like diabetes, liver disease, heartburn, gallbladder disease, heart disease, high blood pressure, abnormal blood fat levels, hormonal changes, bone and joint problems, sleep apnea, several types of cancer and even mental health problems. It might also affect one’s overall quality of life and lead to societal discrimination and stigma.
As per estimations, the annual medical cost of adult obesity in the U.S. is somewhere between 147 billion to nearly 210 billion dollars. This makes the healthcare costs for people with obesity $1429 more than those for people with healthy weight. The UK’s healthcare system estimates the cost of managing obesity-related diseases at around 5 billion pounds (6.5 billion U.S. dollars) per year, which might increase to 10 billion pounds (13 billion dollars) by 2050. This significant economic impact has led to an urgent demand for effective treatments for obesity.
Treatments for obesity include weight loss surgery, medications, and lifestyle changes like dieting and exercise. However, these aren’t always enough to treat severe obesity. Some medications show promise, but their long-term effectiveness is still being researched. Although dieting and exercise may lead to weight loss in the short term, many patients find it difficult to stick to these lifestyle changes long-term, leading to weight regain and lesser health benefits after some time.
In contrast, weight loss surgery can lead to large, long-term weight loss. Depending on the individual, bariatric surgery can help patients lose between 50% and 75% of their extra body weight, and some research shows that the lost weight can be kept off for up to 16 years after surgery. This procedure is currently the most effective treatment for severe obesity. Because of this, more and more people are undergoing weight loss surgery across the world, which is also due to increased awareness, media attention, greater insurance coverage, and improved safety of the procedures.
Weight loss surgeries can be categorized into three main types based on how they work: restrictive, combined (restrictive and malabsorptive), and primarily malabsorptive. Each type of surgery helps patients lose weight in different ways. Restrictive surgeries include procedures like gastric banding and sleeve gastrectomy. RYGB, a combined restrictive and malabsorptive procedure first introduced in 1966, and sleeve gastrectomy are currently the most commonly performed weight loss procedures worldwide.
Anatomy and Physiology of Roux-en-Y Gastric Bypass
The stomach can be found in the upper section of your abdomen, located below your diaphragm and slightly to the left. It acts as a connector between your esophagus (food tube) and the first section of your small intestine (duodenum). The stomach has five main areas:
-Cardia: This is where food enters the stomach, coming from the esophagus.
-Fundus: The dome-shaped part lying above and to the left of the cardia.
-Body: The body is the stomach’s largest part, situated below the fundus, and touching the left diaphragm.
-Antrum: The lower section of the stomach, connecting to the body of the stomach. It holds partially digested food until it’s ready to pass into the small intestine.
-Pylorus: The funnel-shaped region that links the stomach to the duodenum. It leads to the narrower pyloric canal, connected to the duodenum. A muscular ring, known as the pyloric sphincter, regulates when the stomach empties.
The stomach wall has five layers:
-Mucosa: This innermost layer is where nearly all stomach cancers start. It has further sub-layers, including cells that create mucus, stomach acid, a protein-digesting enzyme, and hormones that help control digestion.
-Submucosa: This supportive layer is just underneath the mucosa.
-Muscularis propria: A thick muscle layer that moves and mixes the stomach contents.
-Subserosa: A layer that provides necessary veins, arteries, and nerves.
-Serosa: The outermost layer, wrapping the stomach.
When the stomach is relaxed, the mucosa and submucosa form folds called rugae.
The stomach gets its blood supply from the celiac trunk, the common hepatic artery, and left gastric artery among others. It also has several ligaments that anchor it in place.
The stomach’s nerves come from both the autonomic and enteric nervous systems. The parasympathetic nerves increase stomach activity, and sympathetic nerves slow it down.
Why do People Need Roux-en-Y Gastric Bypass
Obesity treatment has come a long way since the National Institutes of Health put out their views on stomach surgery for severe obesity in 1991. We now know a lot more about obesity and metabolic and bariatric surgery (MBS) which is a type of surgery that helps people lose weight. This is thanks to many doctors’ experiences and research over the years. Reports show that MBS is generally safe and effective for treating serious obesity and related health issues, and it helps reduce death rates compared to treatments that don’t involve surgery.
In 2022, the American Society of Metabolic and Bariatric Surgery along with the International Federation for the Surgery of Obesity and Metabolic Disorders updated guidelines on who should consider MBS.
The guidelines suggest MBS for the following people:
- Those with a Body Mass Index (BMI; a measure of body fat based on height and weight) of 35 kg/m2 or more, whether or not they have other health issues.
- People with type 2 diabetes who have a BMI of 30 kg/m2 or more .
- Those with a BMI between 30 and 34.9 kg/m2 who haven’t achieved significant or lasting weight loss or improvements in other health issues with non-surgical methods.
- Children and teenagers with a BMI more than 120% of the 95th percentile and having major health issues, or a BMI over 140% of the 95th percentile. They should be considered for MBS after being evaluated by a team of health professionals at a specialty center.
- People of any age. Elderly people who could benefit from MBS should be considered for surgery after a thorough check of health issues and frailty. Individuals considered high risk for regular surgery might also benefit from MBS.
It’s important to note that the usual BMI ranges used to define obesity might not apply in the same way to every population. For instance, in Asian populations, clinical obesity is typically defined as a BMI over 25 kg/m2. Everyone deserves a shot at MBS if it can help them, regardless of their BMI.
MBS can also benefit patients who need other special surgeries like joint replacement, hernia repair in the abdomen, or organ transplantation due to their severe obesity.
Before the surgery, it’s crucial to consult with a team of experts to manage any risk factors that can be controlled. This can help lower the risk of problems during or after the surgery and improve the results. The surgeon should be the one to decide when the patient is ready for surgery.
When a Person Should Avoid Roux-en-Y Gastric Bypass
There are some situations when a certain type of weight-loss surgery called Roux-en-Y gastric bypass (RYGB) may not be recommended, these are called “relative contraindications”. These include:
- Having an inflammatory disease or disorder of the digestive system like ulcers, severe dangerous inflammation of the esophagus known as esophagitis, or Crohn’s disease (a condition that causes inflammation of the digestive tract).
- Unmanaged mental health conditions such as substance and alcohol use problems, active psychotic disorders, or recent history of suicide attempts.
- Severe intellectual disability that may affect understanding of the risks and lifestyle changes related to the surgery.
- Epilepsy, a neurological disorder that causes frequent seizures. People with epilepsy may need to review their medications before surgery as the absorption of their medications can be altered by the surgery. A discussion with a pharmacist and a neurologist should be made before the surgery to make an informed decision.
- Allergies to materials used during surgery.
- Long-term use of steroids.
- Conditions that could cause bleeding in the esophagus or stomach like esophageal or gastric varices (enlarged veins), or intestinal telangiectasia (abnormal blood vessels).
- An active infection in the body.
There are also situations where RYGB is completely ruled out, these are called “absolute contraindications”. They include:
- Being pregnant.
- Having severe and unbearable systemic diseases such as end-stage renal disease (advanced kidney disease), unstable coronary artery disease (heart disease), severe heart failure, cirrhosis (liver disease), portal hypertension (high blood pressure in the vein supplying the liver), and active cancer.
- Inability to tolerate general anesthesia which is used to put patients to sleep during surgery.
Equipment used for Roux-en-Y Gastric Bypass
For the Roux-en-Y Gastric Bypass (RYGB) surgery, many specific tools and machines are needed to make sure the surgery is done well and safely. Here are some of the essentials:
Anesthesia and monitoring equipment: These are required for administering anesthesia, the medicine that ensures you don’t feel pain during surgery. It also includes monitors to continuously check your heart rate, oxygen levels, and blood pressure to keep you safe during the operation.
Patient positioning equipment: This includes things like the operating table and supports that help position you safely and comfortably during surgery.
Laparoscopic tower: This is a combination of a video monitor, camera, air pump, and light source that allows the surgeon to do the surgery with small incisions instead of a big cut.
Trocars: These are tube-like devices that are inserted into your body to allow the surgical instruments to reach your abdomen.
Surgical instruments: Basic tools like scalpels, retractors, and forceps are used to get access to your abdomen. Other special instruments used in laparoscopic surgery include a Nathanson liver retractor, grasping tools, cutting and separating tools, and clip applicators.
Staplers: These specialized staplers help create connections between different parts of your digestive tract and also close off tissue during the surgery.
Suction/irrigation system: A clearing system that keeps the surgical area clean and easy to see by clearing blood and other debris.
Electrocautery devices: These tools use electric current to stop bleeding by clotting blood vessels, and also help cut through tissue.
Gastrointestinal measurement devices: These tools, which can be something like rulers or tubes, measure different parts of your digestive system during the surgery. Not all surgeons use these; it depends on their preference.
Endoscopic equipment: These are special viewing tools that a surgeon may use to look at the new stomach pouch and the new connections in your digestive tract. Whether these are used also depends on the surgeon’s preference.
Sutures: These are used to close up the small cuts where the trocars were inserted.
Dressing materials: These cover your wounds after the operation and can vary depending on what’s needed.
Who is needed to perform Roux-en-Y Gastric Bypass?
A weight-loss operation, also known as a Roux-en-Y gastric bypass (RYGB) procedure, involves a team of medical experts. At the center of this team is a ‘bariatric surgeon’. This is a doctor who specializes in weight loss surgeries. They are trained to perform the operation safely and effectively.
The bariatric surgeon is assisted by a ‘surgical first assistant’. This is another professional who supports the surgeon during the operation. They help make sure everything goes smoothly.
Also present is a ‘surgical technologist’ or ‘operating room nurse’. These are trained medical personnel who play important roles in the surgery, making sure that the surgeon has the right tools at the right time.
Another critical member of the team is the ‘circulating or operating room nurse’. Their job is to monitor the surgery and help maintain a safe and sterile environment in the operating room.
Finally, ‘anesthesia personnel’ are there to manage your pain and comfort before, during, and after the procedure. They will make sure you don’t feel any discomfort during the surgery.
All these professionals work together to ensure the operation goes smoothly and that you’re as comfortable as possible throughout the procedure.
Preparing for Roux-en-Y Gastric Bypass
Getting ready for a weight loss surgery, like a gastric bypass, involves a lot of steps and the help of many healthcare professionals. This includes surgeons, general doctors, dieticians, psychologists, anesthesia doctors, and nurses. The goal is to make sure the patient is in the best overall health and that the surgery goes as smoothly as possible. This means checking on the patient’s general health, diet, mental health, and lifestyle.
As part of the process, doctors will look at the patient’s health history and do a physical examination to check for any conditions that could affect the surgery. This can include heart disease, lung disease, stomach issues, and obesity-related conditions. Laboratory tests are done to check for nutritional deficiencies, such as low iron, vitamin B12, and folate. The function of the liver and kidneys is also checked.
Managing any existing conditions is an important part of getting ready for surgery. For example, if a patient has sleep apnea or type 2 diabetes, these should be managed before the surgery. Heart stress tests, echo tests, or pulmonary function tests might be done if the patient has heart or lung disease. If the patient has diabetes, blood sugar levels need to be well managed. This could mean changing medication or insulin doses.
Dieticians will provide guidance on pre-surgery eating habits and make recommendations for a healthy diet. This might involve some weight loss before the surgery to improve its outcome. Patients might be asked to take specific vitamins such as multivitamins, vitamin D, and calcium to correct deficiencies. A low-calorie diet or a liquid diet might be recommended for 1 to 2 weeks before surgery to reduce liver size and ease the surgery process. Some places recommend a 2-week milk diet for this purpose.
A mental health professional will assess the patient’s mental readiness for surgery. They will screen for things like eating disorders, depression, and anxiety. Counseling can be provided to deal with emotional eating, stress management, and putting into practice healthy ways to deal with problems. Support groups or therapy sessions can be helpful both before and after the surgery.
Patients are advised to stop smoking several weeks before the surgery to reduce the risk of complications like infections, problems with wound healing, and lung issues. An exercise program that fits the patient’s abilities will also be recommended, as this can help improve the results of the surgery.
Women who can become pregnant are advised to delay pregnancy during the period of rapid weight loss which typically lasts for a year after the surgery. This is because rapid weight loss and potential nutrient deficiencies can affect the developing baby. They should receive information about safe and effective birth control. Since obesity can affect fertility, it’s important to discuss birth control use post-surgery when fertility can increase. Oral contraceptive pills may not work as well after weight-loss surgery and can increase the risk of blood clots in obese patients. Non-pill hormonal birth control options may be a better choice.
Patients are given information about the surgery, the risks and benefits, how to take care of themselves after surgery, and the lifestyle changes they will need to make. Patients will also be asked to give their informed consent, which means they understand and agree to move forward with the surgery.
Before the surgery, patients may need to prepare by cleaning out their bowel. They’ll be given instructions on which medications to take or avoid before surgery, including how to manage blood thinner pills and other long-term medications. They’ll be told not to eat or drink anything after midnight on the day before surgery. On the surgery day, the patient will receive blood clot-preventing measures and may be given medication to control stomach acid and prevent nausea.
How is Roux-en-Y Gastric Bypass performed
Advancements in technology, such as better tools and improved views of the area being operated on, have popularized the use of laparoscopic surgery. This type of surgery generally results in quicker recovery times and less pain after the operation. Laparoscopic surgery is now commonly used for weight loss surgeries, with robot-aided methods becoming an increasingly successful choice, particularly for complicated cases. Presently, 96.2% to 98.8% of these procedures are performed using laparoscopic methods. However, traditional laparoscopic surgery has certain drawbacks, including limited visualization and rigid instruments.
Further advancements in surgery and new technology introduced the robotic approach. This approach offers several benefits including better ergonomics, control of the camera, 3-dimensional visualization, and flexible tools which overcome the limitations of the laparoscopy. Despite its benefits, the efficiency and specific role of robotic surgery in weight loss procedures are not thoroughly studied yet. One research suggested that although robotic surgery took longer, it was as safe and effective as laparoscopic surgery.
Regardless if the surgery is done laparoscopically or robotically, the steps in Roux-en-Y gastric bypass remain the same, though they might vary from surgeon to surgeon. The process usually entails creating a small pouch in the stomach, a biliopancreatic limb, a connection between the two parts of the small intestine (jejunojejunostomy), and a connection between the stomach and the small intestine (gastrojejunostomy).
Before the surgery, the patient is placed under general anesthesia. The surgeon then uses several ports (tiny incisions) to access the abdominal cavity and use the surgical instruments. The stomach and the areas around it are exposed to assist in creating the gastric pouch.
In this procedure, a part of the small intestine is used to create the biliopancreatic limb and the jejunojejunostomy. Then, the stomach is connected to the small intestine. The created opening in the intestines is examined for leaks by filling it with saline and inflating it with air or injecting a blue dye, any leaks are then promptly fixed.
Afterward, the incisions made for port placement are patched up and the patient is moved to the recovery area. Here, measures to manage pain and monitor for complications are taken, and a diet initially consisting of clear liquids is begun. The recommended stay in the hospital is for safety reasons. However, with advances in recovery methods after surgery, patients are usually discharged within two to three days post-surgery.
Possible Complications of Roux-en-Y Gastric Bypass
Bariatric surgery is a medical procedure performed to help severely obese people lose weight, however, it can come with certain risks. It’s important to note that these complications can be early (occurring within a month of the surgery) or they can be late (occurring more than a month after surgery). The mortality rate for a type of bariatric surgery called Roux-en-Y gastric bypass (RYGB) is around 0.2%, which is higher than other forms of weight loss surgery.
One type of potential early complication is known as an anastomotic leak. This is a small hole that forms along the surgical connection between two parts of your intestine. The hole allows fluids to leak out into your abdomen. If this happens, you may experience a fast heart rate, shortness of breath, fever, left shoulder pain, and abdominal pain. Your doctor might suspect that a leak has occurred, and order a CT scan or an upper gastrointestinal series (a kind of x-ray).
If you’re in a stable condition, the leak might be managed without surgery. In these cases, you’d be given intravenous antibiotics and kept on a diet without food or drink to minimize the leak. Other treatment options might include endoscopic stent placement or clipping to seal the leak. However, if you’re in a critical condition, for instance, if your vital signs are unstable and you exhibit signs of a serious blood infection called sepsis, you may need to go back to the operating room for additional surgery.
Bleeding after surgery is another possibility, and it sometimes requires a blood transfusion. Symptoms might include a fast heart rate, black tarry stools (melena), or passing bright red blood from the rectum (hematochezia). To manage the bleeding, doctors would monitor your condition, and if needed, perform a procedure to stop the bleeding or potentially another surgery if necessary.
Another complication of RYGB is obstruction which can occur at different points along your digestive system. Symptoms might include nausea, vomiting, and a sense of fullness in your upper abdomen. If an obstruction is suspected, fluids and food would be withheld until your symptoms improve. If symptoms persist, you may need to receive nutrition intravenously. Additionally, a feeding tube might be placed to help cope with the obstruction. Surgery is rarely required for this issue.
What Else Should I Know About Roux-en-Y Gastric Bypass?
Roux-en-Y gastric bypass (RYGB) is a type of weight loss surgery that has shown great results in helping people lose a lot of weight and also improve other health problems related to obesity. People who have this surgery typically lose between 60% and 70% of their excess body weight. A key study published in the New England Journal of Medicine found that after 12 years, patients managed to keep off significant weight—around 35 kg. This amount of weight loss is much more than what is usually seen in people who tried to lose weight without surgery over the same time period.
The impact of RYGB on other health problems is particularly noticeable in treating type 2 diabetes, high blood pressure, and high levels of fats in the blood (hyperlipidemia). This study also reported that over half of the diabetes patients were free from the disease 12 years after the surgery. Other large studies have found similar results, showing that RYGB and sleeve gastrectomy (SG, another type of weight-loss surgery) generally help people lose more weight and get rid of their diabetes better than gastric banding (yet another type of weight-loss surgery) and non-surgical treatments. The changes in the body after RYGB, like eating fewer calories and changes in levels of certain hormones, help lower levels of HbA1c (a measure of long-term blood sugar control) and fasting glucose (blood sugar level after not eating or drinking for a while), therefore reducing the effects of diabetes-related complications.
Moreover, RYGB has proven to be successful in reducing high blood pressure and improving abnormal levels of blood fats. However, while levels of triglycerides (a type of fat in your blood) improve significantly, managing cholesterol is a bit more complicated, with varying levels of different types of cholesterol. This variation suggests that the process of fat metabolism after surgery can be complex. Despite these mixed results, the overall improvement in health problems, including high blood pressure and hyperlipidemia, tends to be greater with RYGB than with sleeve gastrectomy, making RYGB the preferred surgical option for reducing these complications from obesity.
In conclusion, RYGB provides long-lasting and significant health benefits apart from just weight loss, making it an important treatment option for people with severe obesity and related health issues. These accomplishments underline the value of considering RYGB for weight management and its substantial influence on improving and potentially solving health problems related to obesity.