Roux-en-Y gastric bypass, Single anastomosis gastric bypass, weight-loss bariatric surgery

Roux-en-Y gastric bypass (RYGB) is a type of weight-loss surgery (bariatric surgery) designed to help people with severe obesity lose weight and improve or resolve related health issues such as type 2 diabetes, high blood pressure, and sleep apnea.

Roux-en-Y gastric bypass

Roux-en-Y gastric bypass is a type of weight-loss (bariatric) surgery that involves creating a small pouch from the stomach and connecting it directly to the small intestine, bypassing a large part of the stomach and the first portion of the small intestine. This procedure reduces the amount of food you can eat and limits the absorption of nutrients, leading to weight loss and improvement in obesity-related conditions.

How it Works

The surgery has two main components:

• Stomach Reduction: A small pouch is created from the upper portion of the stomach. This pouch becomes the new, smaller stomach — about the size of an egg — and drastically limits food intake.
• Intestinal Bypass: The small intestine is divided, and the lower part (the “Roux limb”) is connected to the new stomach pouch. The bypassed portion (the remaining stomach and the first part of the small intestine) is reconnected further down, allowing digestive juices to mix with food.

This results in reduced calorie and nutrient absorption (malabsorption), a smaller capacity for food (restriction), and hormonal changes that help reduce appetite and improve blood sugar control.

Benefits

• Significant and sustained weight loss (typically 60–80% of excess weight).
• Improvement or resolution of obesity-related conditions.
• Long track record of safety and effectiveness.

Risks and Considerations

• Surgical risks: bleeding, infection, blood clots.
• Long-term risks: dumping syndrome, nutritional deficiencies (especially B12, iron, calcium), bowel obstruction, ulcers.
• Lifelong commitment to vitamin supplementation and follow-up.

In some days, Roux-en-Y gastric bypass was the best bariatric surgery; till now it has very consistent results, but it is technically more difficult than the sleeve gastrectomy, and that’s why it has come to the second position nowadays. We form a pouch in the stomach, its size is about 15- 30ml, and its opening is 1.5cm (0.5 inch). Average weight loss is 70% of the excess weight. It was well known as “the pouch tool for bariatric surgical procedure”.

Procedure:

We do small incisions in which we insert our trocars through which the instruments enter the abdomen, we explore the abdomen. We keep a small part of the stomach which is attached to the esophagus, cut the rest part and the small intestine, and then connect or anastomose the 2 ends. As a result, the food enters into a part of the small intestine without enzymes, to meet the enzymes in the Y. We can manipulate the weight loss through the position of the area of anastomosis. The more distal, the more weight loss.

Single anastomosis/gastric bypass

A modification of a sleeve gastrectomy to add some sort of malabsorption. We anastomose a loop of jejunum to the stomach after stapling it at the greater curvature. In this operation, we do not remove the remaining stomach, we keep it, so we have 2 pathways: a pathway for food entering to meet the digestive enzymes in the small intestine at the point of anastomosis. It is called the many gastric bypass.

Advantages:

• The operation has a malabsorptive element.
• The remaining part of the stomach is not removed, so it is reversible.
• It is technically easier than the Roux-en-Y gastric bypass.

Disadvantages:

It doesn’t have consistent results.

New procedures

To minimize the cost.

Gastric plication

We crumple the greater curvature of the stomach on its axis in an attempt to narrow the lumen of the stomach. So, we can produce an effect comparable to sleeve gastrectomy. It is an inconsistent surgery, sometimes, the crumpled stomach can undergo necrosis. and complications, so it’s not very popular. It has the advantage that we use ordinary sutures, not staples, to narrow the stomach.

Sleeve bypass

(Natural orifice transcelomic endoscopic surgery): We do not do incisions in the skin of the abdomen. We enter the abdominal cavity through the vaging, for example, and perform our surgery. Due to the huge expenses of the equipment and the difficulty of the approach, it doesn’t gain so much popularity.

SILS (single incision lap surgery): here we do a single large incision in the umbilicus and, through a special device, put all the equipment through this device and do the surgery, but it is not very promising.

Post-operative Care

Post-operative instructions: After surgery, patients should remain on a high-protein and low-fat diet and supplement their diet with multivitamins, iron, and calcium, usually on a twice-daily basis. Ursodiol may be given to minimize the risk of developing gallstones during the period of acute weight loss. Patients must modify their eating habits by avoiding chewy meats & other foods that may inhibit normal emptying of their stomach pouch.

Post-operative tests

Nutritional and metabolic blood tests must be performed on a frequent basis; at 6 months & 12 months after surgery, and then annually thereafter.

Post-operative body contouring

• Massive weight loss is associated with negative consequences for the body. such as flabby skin, abdominal skin overhang & pendulous breasts.
• The excess skin does not regain the tightness it had before the weight gain. Redundant rolls of tissue may also be associated with intertrigo & significant hygiene problems.
• Surgical correction of these body deformities can significantly enhance physical & physiologic changes. Examples include abdominoplasty, buttock lift, thigh lift, mastopexy, etc.
• The usual time lapse between gastric bypass & plastic surgery procedures is (12-18 months).

Complications of Bariatric Surgery

• Heavy patients are prone to certain hazards due to their weight during transport, positioning on the operating table, and during endotracheal intubation.
• Delayed recovery from anesthesia with possible need for post-operative mechanical ventilation.
• ↑ Risk of deep vein thrombosis (DVT).
• Post-operative hemorrhage from the stapled cut-edge of the stomach.
• Leakage of gastric or intestinal content through a defective staple line or sutured anastomosis.
• Intra-operative injury to the esophagus or spleen.
• Excess skin.
• Hair loss: Usually, temporary. Cause: protein, vitamin A, and mineral deficiencies.
• Post-operative depression: Food issues, Changes in relationships.

Effectiveness of bariatric surgical procedures:

• Reduction of obesity-related comorbidities.
• Lower medication costs and the number of sick days.
• Significant reduction in overall and cause-specific mortality.
• There have been dramatic improvements in the safety of bariatric procedures in the past decade because of the introduction of the laparoscopic procedure, Bariatric surgery is associated with significant peri-operative complication and even mortality. We must know this and tell patients this. It has low mortality, but there are complications.
• The benefit of bariatric surgery was strongest in patients with a BMI of more than 40.
• The mean overall percentage of excess weight loss was 61 percent.
• Overall mortality is less than 1 percent, while adverse events occurred in approximately 20%.
• Diabetes mellitus was completely resolved in 77%.
• Hypertension resolved in 62%.
• Obstructive sleep apnea resolved in 86%.

New frontiers:

• Management of type 2 DM (metabolic surgery).
• Investigative innovations (or using the advanced technology we have nowadays) to minimize the surgery needs.
• (E.g.) endoscopic insertion of a jujemal sheath to produce malabsorption, then, after we gain the desired weight loss, we can remove it or dismantle it and leave it to pass with the stools. Another example: we can put some electrodes in the stomach, trying to do some electro-coagulation to mimic the effect of sleeve gastrectomy, but all of this is in trials nowadays.
• Pushing the indications in some centers for pediatric obesity procedures. bariatric surgery is only performed in adults, but when we have a child is 9, 10 or 11 years with severe obesity and his parents and family need a solution, it is very difficult problem to answer nowadays but, in some centers, they began to perform surgeries in them because those patients are inactive and susceptible to bullying in schools and colleges and they may suffer from severe psychological problems.

Note that!!!

• Bariatric surgery effectively achieves clinically significant, permanent weight loss with low rates of complications.
• Bariatric surgery results in significant improvement in health risks associated with obesity.
• Surgical weight loss increases life span.
• Surgical therapy is cost-effective.

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