Roux-en-Y Gastric Bypass
The Roux-en-Y gastric bypass is the most frequently performed weight loss procedures in the United States. In this procedure, the surgeon creates a small stomach pouch, about the size of a large egg. The pouch is created by dividing the small intestine just beyond the first 50cm of small intestine, also called the duodenum, for the purpose of pulling it up and attaching it with the newly formed stomach pouch. The other end of the small intestine is connected into the side of the Roux limb (the portion of the small intestine attached to the new small stomach) creating the “Y” shape that gives the technique its name.
There are some distinct advantages of the laparoscopic Roux-en-Y gastric bypass over other procedures. The first is the fact that most patients lose weight for the first year and a half. In essence, the surgery forces you to change your eating habits. There is a “golden period” after gastric bypass – the time when the body becomes accustomed to less food and patients have an easier time developing good eating habits. Simply put the gastric bypass requires less willpower than a band to be successful early on. However, in the long term they both require a commitment to change, including the way patients eat. There is strong data which shows that with gastric bypass surgery, many people lose the majority of their excess weight and are successful in keeping it off.
Some gastric bypass patients experience vitamin and mineral deficiencies, including deficiencies of B1 (thiamine), B12, iron and calcium. Your doctor may recommend blood tests to determine that you are getting the appropriate nutrients and may recommend supplements if you are not. If you have symptoms related to vitamin or mineral deficiencies, such as headaches, fatigue, nausea or you simply don’t feel well, you should tell your doctor.
Dumping syndrome may occur in up to 40% percent of people who have had Roux-en-Y gastric bypass. In dumping syndrome, food and juices from your stomach move to your small intestine in an unregulated, abnormally fast manner. Gastrointestinal hormones also are believed to play a role in this rapid dumping process. Most people with dumping syndrome experience signs and symptoms soon after eating. In other people, they may occur later, one to three hours after eating, and they can range from mild or moderate to severe and debilitating. Most of the time, dumping syndrome improves on its own.
When signs and symptoms occur during a meal or within 15 to 30 minutes following a meal, they may include:
- Abdominal pain or cramps
- Dizziness and lightheadedness
- Bloating or belching
- Heart palpitations or rapid heart rate
Sometimes dumping can occur up to 2 hours later. These symptoms include:
- Weakness and fatigue
- Dizziness and lightheadedness
- Feelings of anxiety or nervousness
- Heart palpitations or rapid heart rate
- Mental confusion
Some people experience both early and late signs and symptoms. Conditions such as dizziness and heart palpitations can occur either early or late or both. No matter when problems develop, however, they may be worse in the aftermath of a high-carbohydrate meal, especially one that’s rich in sugars such as sucrose (table sugar) or fructose (fruit sugar.)
Some people also experience low blood sugar (hypoglycemia), related to excess levels of insulin delivered to the bloodstream as part of the syndrome. Insulin influences your tissues to take up the sugar present in your bloodstream and then patients get symptoms from low blood sugar. Because low blood sugar is sometimes associated with severe dumping syndrome, your doctor may order a test to measure your blood sugar level at the peak time of your symptoms to help confirm the diagnosis. Most cases of dumping syndrome improve without any treatment, typically in several months to about a year after signs and symptoms begin. However, if they don’t improve on their own, or if you want relief from symptoms soon after they appear, your doctor may advise one or more treatment options to slow the emptying of your stomach’s contents. The choices for managing dumping syndrome include dietary changes, medications and surgery.
Adjusting your diet may relieve your symptoms. Here are some strategies that you may employ to help deal with dumping.
- Avoid fluids with meals. Drink liquids only between meals.
- Change the makeup of your diet. Consume more low-carbohydrate foods or more food high in protein. Read labels on packaged food before buying, with the goal of not only avoiding foods with sugar in their ingredients, but also staying away from alternative names for sugar, such as glucose, sucrose, fructose, dextrose, honey and corn syrup. Artificial sweeteners are acceptable alternatives. Consume more protein in your diet, and adopt a higher fiber diet.
- Stay away from acidic foods. Tomatoes and citrus fruits are harder for some people to digest.
- Use low-fat cooking methods. Prepare meat and other foods by broiling, baking or grilling.
Wound infections can occur after all types of surgery. When independent evaluators look at surgical wounds they find about five percent of patients get wound infections. These can be minor or major. Major infections can include fever, hot skin around a wound site, leakage from the wound, and redness of the area. These infections may require antibiotics or surgery. It is important to tell your doctor if you think you have an infection. The most common site for an infection after laparoscopic Roux-en-Y gastric bypass is the biggest incision on the left side.
As the connection between your new small stomach and the small intestine heals, it forms scar tissue, which naturally tends to shrink over time, making the opening smaller. This is called a stricture or a stenosis. Usually, the passage of food through an anastamosis will keep it stretched open, but if the inflammation and healing process outpaces the stretching process, scarring may make the opening so small that even liquids can no longer pass through it. The solution is a procedure called gastroendoscopy, and stretching of the connection by inflating a balloon inside it. Sometimes this manipulation may have to be performed more than once to achieve lasting correction. Even more rarely stents or repeat operations are required.
Many blood vessels must be cut, to divide the stomach and to move the bowel. Any of these may later begin bleeding, either into the abdomen (intra-abdominal hemorrhage), or into the bowel itself (gastrointestinal hemorrhage). Transfusions may be needed, and re-operation is sometimes necessary. Use of blood thinners, to prevent venous thromboembolic disease, may actually increase the risk of hemorrhage slightly.
Infection can occur after surgery. Effective short-term use of antibiotics, diligent respiratory therapy, and encouragement of activity within a few hours after surgery, can reduce the risks of infections.
An internal hernia is when the small bowl protrudes through a space that is normally not there. This happens totally inside the abdominal cavity and usually occurs more than one year after a gastric bypass. The most common signs of a hernia are severe abdominal pain in the mid-abdomen that starts suddenly, cannot be relieved, and then, suddenly goes away. Surgery may be necessary to diagnose and correct this problem.
Abdominal surgery always results in some scarring of the bowel, called adhesions. No matter what surgery you have on the bowel there is a one to two percent lifetime risk of adhesions forming and blocking the bowel. When a patient’s bowels become blocked, the patient generally has severe abdominal pain and eventually vomiting. Vomiting is always abnormal after surgery. The treatment for bowel obstruction is surgery.
Any injury, such as a surgical operation, causes the body to increase the coagulation of the blood. There is an increased probability of formation of clots in the veins of the legs, or sometimes the pelvis, in the morbidly obese patient. A clot which breaks free and floats to the lungs is called a pulmonary embolism, a very dangerous occurrence. Commonly, blood thinners are administered before surgery, to reduce the probability of this type of complication. The best way to prevent this life threatening complication is to walk after surgery.
An anastamosis is a surgical connection between the stomach and bowel, or between two parts of the bowel. The surgeon attempts to create a water-tight connection by connecting the two organs with either staples or sutures, either of which actually makes a hole in the bowel wall. The surgeon will rely on the healing power of the body, and its ability to create a seal like a self-sealing tire. If that seal fails to form, fluid from within the gastrointestinal tract can leak into the sterile abdominal cavity and give rise to infection and abscess formation. Leakage of an anastamosis has been reported in up to two percent of gastric bypass procedures, usually at the stomach-bowel connection. Sometimes leakage can be treated with antibiotics, and sometimes it will require immediate re-operation.
Almost any of the above complications can result in death. The best way to avoid the most common causes of death after gastric bypass surgery is to walk frequently and to report any problems to your surgeon.