The Anatomy of the Roux-en-Y Gastric Bypass

[MsJacquiiC]

The Roux-en-Y Gastric Bypass Surgery (aka the RYGB) procedure reduces caloric intake by altering the gastrointestinal tract two ways: through a restrictive and malabsorptive procedure. The Restrictive part

The Roux-en-Y is restrictive and malabsorptive. It restricts intake and also lessens the absorption of food.

of the procedure cuts down on the amount of food you can take in by tying or stapling off a little portion of the stomach, thus creating a miniature stomach, and leaving only a narrow outlet from which the food travels into the rest of the digestive tract and out in the normal manner. The stomach is reduced from a four-pint capacity to about a half-cup, and the lower outlet of the pouch is only about ? inch in diameter.

The malabsorptive part of the procedure, also called gastric bypass, bypasses about two feet of the small intestine, the originally twenty-foot long tube where nutrient absorption occurs. Consequently, the food travels a shorter route, and fewer calories are absorbed. The lower end of the intestine, called the Roux limb, is brought up to the little stomach or ?pouch? and attached to provide material with an exit. The other cut end is sewn back onto the intestine further down, to allow bile and pancreatic secretions into the small intestine so that digestion can proceed and nutrients can be absorbed. In essence most of the stomach if bypassed, all of the duodenum is bypassed, and the pyloric sphincter (the mechanism that controls the rate of entry of food into the small intestine) is bypassed.


What are the Gastric Bypass Surgery risks?
In general, the more extensive the operation, the greater the risk of complications and nutritional deficiencies. My procedure was done laparoscopically, thus reducing my risk, though the procedure is still considered Major Surgery.

Although RYGB is currently the most popular form of gastric bypass surgery, it does carry other risks. The risk of actually dying can be up to one percent, and the risk of serious complications is as high as ten percent. The leading cause of death is pulmonary embolism caused by deep vein thrombosis (a blood clot deep in a leg vein that breaks loose and travels to the lungs where it blocks a lung artery). This is something that I was worried about. To prevent this from happening I was initially required to move my feet and legs for a minimum of 10 -15 minutes every hour. On the day after surgery I was required to actually get up and take numerous short walks. As I have stated before, walking also helps move and dissipate the gas that is used to inflate the abdominal area during the surgery, but more importantly, it helps prevent blood clots. Finally, I was given Heprian, an anti-coagulant drug that is used chiefly in the treatment of thrombosis.

Gastric Bypass post surgery risks include abdominal hernias, which are the most common complication requiring surgery, but are much more common with "open" surgery where the procedure is done manually through a large incision.

Uncommon gastric bypass surgery risks can include the rare complications of: leakage from around staples or sutures, ulcers in the stomach or small intestine, blood clots in the lungs or legs, stretching of the pouch or esophagus, persistent vomiting and abdominal pain, inflammation of the gallbladder, and failure to lose weight (very rare).

More than one-third of obese patients who have weight-loss surgery develop gallstones. Gallstones are clumps of cholesterol and other matter that form in the gallbladder. During rapid or substantial weight loss, a person?s risk of developing gallstones increases. Gallstone formation can be lessened with medication taken for the first six months after surgery.

Since the connection between the stomach and intestines has narrowed, patients can experience vomiting and nausea after eating, though these are not universal side effects and normally only afflict a minority of patients, however vomiting and nausea are very likely to occur in patients who continue to eat highly refined, high-calorie foods, including sweets. Because many gastric bypass patients have poor dietary histories, this is considered a genuine risk.

Nearly 30 percent of patients who have weight loss surgery develop nutritional conditions such as anemia, osteoporosis, and metabolic bone disease. Because the small intestine is largely bypassed, minerals and vitamins can not be effectively absorbed from food. As a result deficiencies in iron, vitamin B12, calcium or magnesium can occur. These can be avoided if vitamin and mineral supplements are taken as recommended, on a continuing, life-long basis. Of those who do develop an iron deficiency, 50 percent develop anemia, a blood disease that can result in paleness and feelings of fatigue.

To avoid this and keep nutrition under control, doctors often recommend gastric bypass patients work with a dietitian to plan meals.

Another risk to consider involves what patients won't be able to have. A common procedure for early detection of gastric cancer is endoscopy, wherein a visual examination is conducted by passing an endoscope through a patient's mouth, down the esophagus and into the stomach and small intestines. The structure of the gastric bypass makes this procedure out of the question, thus adding another potential health risk for bypass patients.

Women of childbearing age should avoid pregnancy for 18 months to two years after surgery, until their weight becomes stable, because rapid weight loss and nutritional deficiencies can harm a developing fetus.

Non-steroidal anti-inflammatory drugs (NSAIDS) such as ibuprofen and many arthritis drugs that contain aspirin may not be taken after this surgery.

Smoking after weight-loss surgery may cause ulcers in addition to other known health risks.

Gastric bypass reversal is complex and is only performed if medically necessary.

Benefits of Gastric Bypass Surgery
Most weight-loss surgery patients will lose between 60 to 80 percent of their excess body weight with the gastric bypass procedure. Substantial weight loss occurs 18 to 24 months after surgery; some weight regain is normal and can be expected two to five years after surgery.

In addition to weight loss, surgery has been found to have a beneficial effect on many other medical conditions such as: diabetes, hypertension, acid reflux, sleep apnea, polycystic ovary syndrome (PCOS), urinary stress incontinence, low back pain and many others. Cleveland Clinic research has shown that 80 percent of their diabetic patients had remission from their diabetes (patients? blood sugar levels were normal without medication). In addition, many patients report an improvement in mood and other aspects of psychosocial functioning after surgery.

After gastric bypass surgery, your overall quality of life is improved. Many weight-loss surgery patients express elation on being able to do things that may seem trivial to the non-obese person, such as going to the store, playing with their children, getting in and out of a car, riding a roller coaster, shopping for regular-sized clothes ? the list is endless.

Typically, weight-loss surgery is performed laparoscopically (minimal invasive surgery). Patients will often experience shorter hospital stays, smaller incisions and quicker recovery periods.

Medical conditions that may be greatly improved after gastric bypass surgery include:

1. High blood pressure. At least 70 percent of patients who have high blood pressure, and who are taking medications to control it, are able to stop all medications and have a normal blood pressure typically two to three months after surgery. When medications are still required, their dosage can often be lowered, without reduction of medication side effects.
   
   
2. High cholesterol. More than 80 percent of patients will develop normal cholesterol levels two to three months after the operation.
   
   
3. Heart disease. Although it can't be said definitively that heart disease is reduced, the improvement in problems such as high blood pressure, high cholesterol and diabetes certainly suggests that risk reduction is very likely. In one recent study, the risk of death from cardiovascular disease was found to be profoundly reduced in diabetic patients who are particularly susceptible to this problem. It may be many years before further proof exists, since there is no easy and safe test for heart disease.
   
   
4. Diabetes. More than 90 percent of Type II diabetics experience, usually within a few weeks after surgery: normal blood sugar levels, normal Hemoglobin A1C values, and freedom from all their medications, including insulin injections. Based upon numerous studies of diabetes and the control of its complications, it is likely that the problems associated with diabetes will slow in their progression when blood sugar is maintained at normal values. There is no medical treatment for diabetes that can achieve as complete and profound an effect as gastric bypass surgery ? which has led some physicians to suggest that gastric bypass surgery may be the best treatment for diabetes in the seriously obese patient. Abnormal glucose tolerance, or "borderline diabetes," is even more reliably reversed by gastric bypass. Since this condition becomes diabetes in many cases, the operation can frequently prevent diabetes as well. Another recent analysis showed that 84 percent of those who underwent Roux-en-Y gastric bypass experienced complete reversal of their type 2 diabetes. Most of them stopped their oral medications or insulin before they even left the hospital, so the remission was apparently not due to weight loss alone. As a result, gastric bypass surgery is being explored as a cure for type 2 diabetes in normal weight or moderately overweight people. Recently, the RYGB procedure was used on two mildly overweight patients. Within a month post-surgery, these patients had dramatically lower fasting glucose, fasting insulin, and A1c's.
   
   
5. Asthma. Most asthmatics find that they have fewer and less severe attacks, or sometimes none at all. When asthma is associated with gastro esophageal reflux disease, it is particularly benefited by gastric bypass.
   
   
6. Respiratory insufficiency. Improvement of exercise tolerance and breathing ability usually occur within the first few months after gastric bypass surgery. Often, patients who have barely been able to walk find that they are now able to participate in family activities ? even sports.
   
   
7. Sleep apnea syndrome. Dramatic relief of sleep apnea occurs as patients lose weight. Many report that within a year of gastric bypass surgery, their symptoms were completely gone, and they had even stopped snoring completely ? even their spouses agreed. Many patients who require an accessory breathing apparatus to treat sleep apnea no longer need it after a surgical weight-loss procedure.
   
   
8. Gastro esophageal reflux disease. Relief of all symptoms of reflux usually occurs within a few days of gastric bypass surgery for nearly all patients.
   
   
9. Gallbladder disease. When gallbladder disease is present at the time of the surgery, it is "cured" by removing the gallbladder during the surgical weight-loss procedure. If the gallbladder is not removed, there is some increase in risk of developing gallstones after the surgery, and occasionally, removal of the gallbladder may be necessary at a later time.
   
   
10. Stress urinary incontinence. This condition responds dramatically to surgical weight loss and usually becomes completely controlled. A person who is still troubled by incontinence can choose to have specific corrective surgery later, with much greater chance of a successful outcome with a reduced body weight.
    
    
11. Low back pain, degenerative disk disease and degenerative joint disease. Patients usually experience considerable relief of pain and disability from degenerative arthritis and disk disease and from pain in the weight-bearing joints. This tends to occur early, with the first 25 to 30 pounds lost, usually within a month after gastric bypass surgery. If there is nerve irritation or structural damage already present, it may not be reversed by weight loss, and some pain may persist.

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Hypertension Also referred to as high blood pressure, HTH, HTN or HPN, hypertension is a medical condition in which the blood pressure is chronically elevated. In current usage, the word "hypertension" without a qualifier normally refers to arterial hypertension. The Mayo Clinic specifies blood pressure is "normal if it's below 120/80".

Sleep Apnea A sleep disorder (a comorbidity often seen in obese patients) characterized by pauses in breathing during sleep. Each episode, called an apnea, lasts long enough so that one or more breaths are missed, and such episodes occur repeatedly throughout sleep. Sleep apnea is diagnosed with an overnight sleep test called a polysomnogram, or a "Sleep Study" which is often conducted by a pulmonologist. A continuous positive airway pressure (CPAP) machine is used mainly by patients for the treatment of sleep apnea at home.

Malabsorption Malabsorption is a clinical term: A state arising from abnormality in the digestion and absorption of food nutrients across the gastrointestinal (GI) tract. The digestion or absorption of a single nutrient component may be impaired, as in lactose intolerance due to lactase deficiency. The Roux-en-Y gastric bypass combines the malabsorption and restrictive techniques to achieve major weightloss.

Roux-en-Y Gastric Bypass A type of gastric bypass procedure which combines restrictive and malabsorption techniques - meaning, it reduces the amount of food a patient can comfortably eat (restriction), and also reduces the amount of calories that can be digested in the small intestine (malabsorption). This combination of bariatric methods leads to greater weight loss and the roux-en-y procedure is seen as one of the best ways to treat clinically severe obesity. See WLS Videos for animated surgery technique.

Obesity Obesity results from the excessive accumulation of fat that exceeds the body's skeletal and physical standards. Obesity has been defined as a weight more than 20% above what is considered normal according to standard age, height, and weight tables, or by a complex formula known as the body mass index. According to the National Institutes of Health (NIH), an increase in 20 percent or more above your ideal body weight is the point at which excess weight becomes a health risk. CLICK HERE TO OPEN THE JOURNEY BMI CALCULATOR!

Bile A digestive juice that is made by the liver, stored in the gallbladder, and excreted into the small intestine where it helps to digest fat.

Gall Bladder A small pear-shaped sac that stores and concentrates bile. It is connected to the liver (which produces the bile) by the hepatic duct. Sometimes the substances contained in bile crystallize in the gall bladder, forming gallstones. These small, hard concretions are more common in persons over 40, especially in women and the obese. They can cause inflammation of the gall bladder, a disorder that produces symptoms similar to those of indigestion, especially after a fatty meal is consumed. Gallstones may pass out of the body spontaneously; however, serious blockage is treated by removing the gall bladder surgically.

Cholesterol A fat-like substance that is made by the body and is found naturally in animal foods such as meat, fish, poultry, eggs, and dairy products. Foods high in cholesterol include organ meats, egg yolks, and dairy fats. Cholesterol is needed to carry out functions such as hormone and vitamin production. When cholesterol levels are too high, some of the cholesterol is deposited on the walls of the blood vessels. Over time, the deposits can build up and cause the blood vessels to narrow and blood flow to decrease. Total blood cholesterol levels above 240 mg/dl are considered high. Levels between 200 and 239 mg/dl are considered borderline high. Levels under 200 mg/dl are considered desirable.

Diabetes Mellitus A disease that occurs when the body is not able to use blood glucose (sugar). Blood sugar levels are controlled by insulin, a hormone in the body that helps move glucose from the blood to muscles and other tissues. Diabetes occurs when the pancreas does not make enough insulin or the body does not respond to the insulin that is made. There are two main types of diabetes mellitus: Type 1 Diabetes and Type 2 Diabetes. All forms of diabetes have been treatable since insulin became medically available in 1921, but there is no cure.

Duodenum The first 12 inches of small intestine immediately below the stomach. Bile and pancreatic fluids flow into the duodenum from the liver and pancreas. Ducts from the pancreas and gallbladder bring in bicarbonate to neutralize stomach acid, pancreatic enzymes to further digestion, and bile salts to break up fats. Nutrient absorption begins in the lower duodenum.

Glucose Also known as dextrose or grape sugar, glucose is a building block for most carbohydrates and occurs in the sap of most plants and in the juice of grapes and other fruits. Digestion causes some carbohydrates to break down into glucose. After digestion, glucose is carried in the blood and goes to body cells where it is used for energy or stored.

Metabolism All of the processes that occur in the body that turn the food you eat into energy your body can use. Exercise, food, and environmental temperature influence metabolism.

Overweight It is defined as a Body Mass Index (BMI) of 25 to 29.9. Body weight comes from fat, muscle, bone, and body water. It is important to remember that although BMI correlates with the amount of body fat, BMI does not directly measure body fat. As a result, some people, such as athletes, may have a BMI that identifies them as over their ideal body weight even though they do not have excess body fat. CLICK HERE TO OPEN THE JOURNEY BMI CALCULATOR!

Surgical Staples Surgical staples are specialized staples used in surgery in place of sutures to close skin wounds. Stapling is much faster than suturing by hand, and also more accurate and consistent. In bariatric surgery, staples are primarily used because staple lines are less likely to leak blood, air or bowel contents. In skin closure, dermal adhesives (skin glues) are also an increasingly common alternative. The technique of stapling for surgery is said to have been influenced by the Roman use of ants for wound closure.

Type 2 Diabetes Previously known as "noninsulin-dependent diabetes mellitus" or "adult-onset diabetes" -- Type 2 diabetes is the most common form of diabetes mellitus. About 90 to 95 percent of people who have diabetes have type 2 diabetes. People with type 2 diabetes produce insulin, but either do not make enough insulin or their bodies do not efficiently use the insulin they make. Most of the people who have this type of diabetes are overweight. Therefore, people with type 2 diabetes may be able to control their condition by losing weight through diet and exercise. They may also need to inject insulin or take medicine along with continuing to follow a healthy program of diet and exercise. Although type 2 diabetes commonly occurs in adults, an increasing number of children and adolescents who are overweight are also developing type 2 diabetes.

Deep Vein Thrombosis Deep vein thrombosis (or deep venous thrombosis and usually abbreviated as DVT) is the formation of a blood clot in a deep vein. Deep vein thrombosis commonly affects the leg veins or the deep veins of the pelvis. Occasionally the veins of the arm are affected (if spontaneous, this is known as Paget-Schr?tter disease). A DVT can occur without symptoms, but in many cases the affected extremity will be painful, swollen, red, warm and the superficial veins may be engorged.

Endoscopy Endoscopy is a minimally invasive medical procedure that is used to assess the interior surfaces of an organ by inserting a tube (generally a medical instrument known as an endoscope) into the body. Many endoscopic procedures are considered to be relatively painless and, at worst, associated with mild discomfort. Eliminating incisions means less risk than traditional open or laparoscopic surgery, minimal post operative pain, fast recovery time and no scarring. The Restorative Obesity Surgery, Endolumenal Procedure better known as The ROSE Procedure is performed endoscopically, as is the StomaphyX gastric bypass revision. Patients generally report minimal or no pain after the procedures and many of them return to work and normal activities the next day.

Pouch Most bariatric surgeries restricts the amount of food a patient can eat by reducing the size of the stomach by gastric banding, stapling or removal. What results is known as the gastric pouch.