Roux-en-Y Gastric Bypass

The Roux-en-Y gastric bypass (RNYGB) has been around in various shapes and forms for over 50 years. It has previously been considered the gold standard of weight loss procedures. With the evolution of new techniques, including the mini gastric bypass (MGB) and sleeve gastrectomy (LSG), this title has been contended. Nonetheless it remains a very effective and safe way to lose large amounts of weight. As well as reduce, improve and resolve the complications and diseases associated with being overweight and obese.

The procedure is now almost always performed laparoscopically which has allowed huge advances in the postoperative care of weight loss patients. The RNYGB and the MGB have somewhat different configurations. But they have similar weight loss outcomes. There is a lot of research going into these procedures, along with the LSG. This data continues to shape the landscape of weight loss surgery. With the primary goal of providing safe and effective long term weight loss in patients burdened with obesity.

How does the Roux-en-Y gastric bypass work?

This type of bypass, like the MGB, is a metabolic procedure. This means that gut physiology changes as a result of the surgery. This is due to an alteration in the very complex array of chemical signals between the gut and the brain. In addition to the restriction of the small gastric pouch, there is a metabolic result. A hormone driven reduction in a patient’s appetite (called appetite suppression). As well as feeling satisfied after eating only a very small volume of solid or liquid (called early satiety).

There is a commonly held belief that the bypass also causes weight loss through malabsorption (impaired absorption of nutrients from the gut). This is not accurate. Studies have shown that the ‘impaired’ absorption resulting from the RNYGB is responsible for about 10% of a patient’s total weight loss. The neurohormonal (chemical signals) changes are far more important.

What can I do to help my success after surgery?

The neurohormonal and metabolic ‘kick’ that the bypass creates has a time limit. It is usually around 9-24 months and varies greatly from patient to patient. For this reason, and to really get the most out of the RNYGB, patient participation is vital.

This means tuning in to your bariatric team and heeding their advice and requests. This may be your surgeon or bariatric physician. But also may be your dietitian, psychologist, exercise physiologist or other people involved in helping you after surgery.When it comes to life after bypass, there are a few basics which you must adhere to:

• A healthy diet. What you are putting in by way of your diet will be different after surgery. We find that patients who take on a protein-rich diet, including plenty of good fats, with fewer cabs generally do well.
• Lots of water. Staying ahead of thirst is key. This means drinking water regularly as a new habit. Your hydration needs are still high, and you can no longer guzzle water if you’re thirsty.
• Extra fibre. Taking in psyllium derived fibre is advisable.
• Daily multivitamins. You will need to take multivitamins every day to ensure your nutrient levels are adequate.
• Regular exercise. About 30 minutes of load bearing exercise 3-4 times a week is beneficial to build and maintain muscle mass. This is in addition to getting out there for swims or walks and other movement in your day.
• Focus on mindset. What’s going on inside is just as important as exercise and diet. We call it being mentally fit. You might find the help of a psychologist invaluable to helping you adopt a killer mindset. Or perhaps a mentor or coach. Whatever works for you. It might even be an insightful friend that helps you stay on track.
• Seek out support. There is lots of support out there for patients after bariatric surgery. From your surgical team itself right through to Facebook groups and meetups. Or if you prefer to go it alone, there are many books on mindset which can help.

How do you perform the Roux-en-Y gastric bypass procedure?

The procedure is performed laparoscopically (keyhole) using the following steps-

1. Five small incisions 5-12mm in size are made in the abdominal wall and ports are placed into the gas filled abdominal cavity. These are used to pass a camera (laparoscope) and tools used by the surgeon to carry out the procedure.
2. The abdominal organs are assessed to ensure the surgery can be completed safely.
3. A small gastric pouch is constructed using a specialized stapler. The larger remnant stomach remains in place.
4. The small intestine is then disconnected around 150 cm from the remnant stomach. The longer (lower) small intestine is then anastomosed (joined) to the small gastric pouch. This join is called the gastrojejunostomy (stomach joined to small intestine). The shorter (upper) small intestine is anastomosed to the lower small intestine approximately 50-100cm below the gastrojejunostomy in a configuration resembling a “Y”- hence the name Roux-en-Y gastric bypass.
5. The replumbing creates some tunnels (mesenteric defects) which are also closed.
6. Sometimes a silicon drain is left in for a short period.
7. The ports are removed, the gas is released and the skin is closed.

Are there risks from the surgery?

Yes, any surgery, no matter how routine, has associated risks. Your surgeon will explain all the risks of gastric bypass to you in detail. It is really important that you understand these risks as clearly as possible. This is part of your surgeon ensuring you make ‘informed consent’ for the procedure.

When we assess risk, we always balance it against the benefits of surgery. This is known as a risk-benefits analysis. Weight loss surgery has been shown to be effective and, more importantly, safe. The major risk profile is comparable to commonly performed procedures like laparoscopic cholecystectomy (gallbladder removal). As well as hysterectomy (removing the uterus) and hip arthroplasty (joint replacement).

The roux-en-Y gastric bypass has a number of risks. This includes leaking of the staple line (or suture breakdown). As well as bleeding, ulcers, stricture (narrowing of a gut join), internal hernia and nutritional deficiencies. There are also risks associated with anaesthetic which are common to all general surgeries.

In addition to your surgeon’s verbal explanation, you will also receive a comprehensive information leaflet. This is from the Royal Australasian College of Surgeons (RACS) and further explains in lay terms the nature of the surgery and the risks involved.