Laparoscopic Roux-en-Y Gastric Bypass Surgery

This procedure is considered the “gold standard” in weight loss surgeries by both the National Institute of Health and the American Society of Bariatric Surgery. It makes up 80% of the weight loss surgeries performed in the United States today, and is considered the most effective in terms of long-term weight loss. It involves a restrictive component in which a portion of the stomach is stapled into a small pouch, and a mildly malabsorptive component, in which approximately 100-125 cm of the small intestine are “bypassed” so food does not absorb along that portion of the small bowel.  

This surgery requires a 24 hour hospital stay, and recovery is usually 10 to 20 days. Long term weight loss averages 75% of excess body weight and usually occurs in the first 12 to 18 months postoperatively. Most insurance companies will cover this procedure if they provide benefits to the patients initially.

The Laparoscopic Gastric Bypass is a powerful tool in the journey to successful weight loss. In order for this procedure to work in the long term however, you must be committed to changing your lifestyle completely – eating less, maintaining proper nutrition and exercising regularly.

The Procedure

In a Laparoscopic Gastric Bypass surgery, stapling creates a small stomach pouch at the very top of the stomach just below the esophagus, restricting the amount of food a patient can eat. The remainder of the stomach is not removed, but is completely stapled shut and divided from the new pouch. Then, the small intestine is divided at the beginning of the jejunum - the middle section of the small intestine. The jejunum is then brought up and attached to the pouch so that food empties directly into it without the normal digestive juices, so calories and nutrients are less completely absorbed. The end of the duodenum, the first section of small intestine, is then reattached downstream from the pouch.

The normal digestive juices from the stomach, liver and pancreas are now mixed with the food for digestion. This section of jejunum from the new pouch to the duodenum is the bypass – named because it bypasses the old stomach and digestive juices.

Clinical studies show the new, smaller pouch contributes greatly to higher overall weight loss success and long-term weight control.

Why the Procedure Works

The smaller stomach pouch now holds about 15cc, or less than an ounce of food in the beginning. This restricts food intake and the body mostly burns fat for everyday energy. The smaller pouch also creates an early sense of fullness, even after eating less than an ounce. As a result, you will fill satisfied and feel less desire to eat.

Weight loss with the Laparoscopic Gastric Bypass is the greatest in the first 12 months. Slowly, over time, the pouch continues to expand until it can hold what is necessary to maintain a healthy weight.

Because normal digestive juices are not present, the bypass does not tolerate food with fats, sugars and starches well. A phenomenon known as 'dumping' occurs when these 'unhealthy' foods are eaten in large quantities or without eating enough protein at the same time. Dumping causes a rapid heart rate, nausea, sweating, and a general feeling of illness.  

As uncomfortable as this side effect is, this physically reinforced behavior modification actually works in your favor – promoting healthy post-surgery eating behavior. Not all patients experience dumping, but those that do find it a helpful reinforcement.  

Possible Risks and Complications

Gastric Bypass surgery provides many benefits for a patient, but has risks as well. You need to take these into consideration as you consider your decision to undergo weight loss surgery. Please study these carefully. These risks and complications can include:

• Pulmonary Embolism
  A pulmonary embolus usually comes from a deep venous thrombosis or blood clot that forms in the veins of the pelvis. A part of the blood clot breaks away and goes up to the lungs, blocking the blood returning to the heart. It can be fatal but occurs in less than 1% of patients who have weight loss surgery.

Before surgery, we take every medical precaution possible to help prevent blood clots. First, when you are being prepped an hour prior to surgery, we treat you with a blood thinner that guards against clotting. Second, you are fitted with pulse stockings for your legs that pneumatically 'squeeze' the blood vessels in your legs – actually 'bruising' your blood and helping to prevent clotting. Third, we get you out of bed soon after surgery and make you walk. Except for in the middle of the   night for sleep, you will be required to walk every two hours for your entire stay in the hospital. This is very important. To help avoid a pulmonary embolism, you need to walk as much as you can while you are in the hospital and when you return home.

These precautions are meant to minimize your risk of a pulmonary embolism, but it can still occur in rare cases.

• Anastomotic Stricture
  Blockage where the small bowel is attached to the stomach. This usually only occurs in about 2.5% of patients. When it does occur, it is usually caused by tissue swollen by surgery. Normally, this internal swelling will go down and doesn't require re-operation. It can occur in the weeks following surgery, so please notify our office if you find yourself having more difficulty swallowing foods and fluids as time passes, rather than less.  

Usually a stricture can be treated by an endoscopy, but in rare cases, the patient will need to be re-operated on to open a blockage.

• Leakage from a Staple Line
  When leakage occurs, it will usually be within the first week of post surgery. We test the staple line twice: once in the operating room and once the morning after surgery. We also leave a small drain in the area to catch any fluid that leaks out while you are in the hospital. This complication occurs in 1-4% nationally of the patients who have weight loss surgery. Our program's leakage rate is less than 1%.

• Pneumonia
  This is an infection in the lungs resulting from collapsed air sacks. It occurs in less than 1% of patients. Patients must work hard on their walking, breathing and coughing exercises after surgery to help prevent pneumonia.

• Infection
  An infection can occur in the midline open wound about 12% of the time and in the small puncture sites from laparoscopic incisions about 1% of the time. Normally, this doesn't require further surgery and is best handled by opening the wound and letting the fluid drain out.

Often times patients mistake decomposing fat for an infection. This is called 'fat necrosis' and creates a clerisy liquid similar to pus.

• Hernia
  A hernia is an opening in the muscle of your abdomen, which allows the intestines to come out underneath the skin. It appears as a large 'bulge' under the skin. Hernias occur in patients undergoing laparoscopic surgery at a very low rate of about 1%. The incidence of hernias is much higher in 'open' versus laparoscopic surgeries.

• Bleeding
  The most common problem with bleeding comes from the raw staple lines and occurs very rarely. This blood is passed out of the rectum with the stool. Almost all patients pass a little blood in their first few stools. Patients rarely need a blood transfusion from post-op bleeding, but it can occur. A second type of bleeding comes from bleeding into the abdomen outside of the intestine. This type of bleeding is extremely rare.

Patients must stop any anti-inflammatory medications, herbal supplements, vitamins, and aspirin prior to surgery. We will review your medications with you prior to surgery to make sure you have stopped any medications that increase your risk of bleeding.

• Vomiting
  Almost all patients experience this complication but it's usually more like 'spitting up' than vomiting. If you begin having a persistent problem with this after surgery, you need to contact the office.

Frequent vomiting is usually caused by eating too fast or overeating and not following the Four Rules.

Other less frequent risks include but are not limited to: perforation of stomach/intestine, injury to spleen, small bowel obstruction, development of gallstones or gallbladder disease, gastric pouch ulcer, weigh gain or failure to lose satisfactory weight, anemia, hair loss, iron deficiency, vitamin deficiency, etc. All of our patients are placed on vitamin and mineral supplementation for life, and blood levels should be checked frequently.

• Death
  The approximate risk of death is 0.5% of all patients having all forms of weight loss surgery in the United States. This means that 1 in 200 patients will die this year having a weight loss procedure. With proper patient workup and selection, this number can be much lower. We have had no patient deaths in our program.