Why is the Roux-en-y Gastric Bypass considered the ‘Gold Standard’ bariatric procedure?
Many people affected by obesity come to me requesting to have the Roux-en-y gastric bypass to treat their obesity.
That is not surprising! The Roux-en-y gastric bypass is the second most popular bariatric operation in the world and is frequently described as the ‘Gold Standard’ in bariatric surgery.
However, many patients (and I dare to say many doctors) do not know what the gastric bypass entails and how it is done. In addition, many patients do not know how it works. If you are one of those, read on!
First of all, what does Roux-en-Y mean? The name come from the surgeon who first described it, César Roux and the stick-figure representation. Diagrammatically, the Roux-en-Y connection between two structures looks a little like the letter Y, hence the Y at the end.
How is the Roux-en-y gastric bypass operation carried out?
The gastric bypass involves several steps.
It might be difficult to understand this, so you need to look at the video!
Step 1: Creation of the small gastric pouch: The first step is to divide the stomach into two parts. A small pouch that is connected to the gullet (oesophagas) and a large part that is connected to the bowel. The two parts are completely separated from each other.
Step 2: Creating the bypass: The second step is to find a part of the small bowel that can reach the small stomach pouch. When found, that part of the bowel is divided into two parts. The part that is away from the stomach will be connected (joined) to the small gastric pouch and will make the food bypass the large part of the stomach and some of the small bowel.
Step 3: Reconnecting the bypassed parts of the gastrointestinal tract: The third step is to connect the other side of the bowel that was divided in step 2, to the bowel that is currently connected to the small gastric pouch about one metre downstream from the first connection (joint).
How does the operation work?
Bypassing the stomach and the small bowel results in hormonal changes that affect hunger, appetite, control of blood sugar and the speed of food going through the bowel.
In addition, the stomach pouch that receives food is small and subsequently the patient will not be able to eat as much.
Why do we need to do all of these steps?
The first two steps of the operation achieve the changes that result in weight loss.
The third step is done to ensure that food that you eat is digested and absorbed. If you are interested to understand further, read the rest!
If the first two steps are done without doing anything else, the food that you swallow will go to the gullet, then to the small stomach pouch and then to the small bowel while bypassing part of the stomach and part of the small bowel. However, the food that you eat will not be digested or absorbed! That is because the food will not meet the digestive juices produced in the stomach, the pancreas and the liver as they are all connected to the small bowel that becomes disconnected from the rest of the bowel after the first two steps. While that is good for weight loss, it is not good for survival! That takes us to the third step: It is done to ensure that the food meets the digestive juices.
Is the a good operation?
The Roux-en-y gastric bypass is a very good operation for obesity. Actually, it used to be described (and possibly is still described) as the gold standard in bariatric surgery. The reason for such description is that it has a good balance between benefits and risks. That is for several reasons.
It results in excellent weight loss (around 30% of the total body weight).
The bypass has a very good possibility of improving the control of or resolving several medical conditions caused by obesity. The possibility of such improvement or resolution of conditions like type 2 diabetes, high blood pressure and reflux disease might be higher than the possibility of resolution or improvement with some of the other bariatric procedures.
It has been tried and tested as a keyhole procedure for more than 25 years and as an open procedure for more than 55 years.
The gastric bypass has a small risk of complications and a very small risk of death.
What are the potential complications of the gastric bypass?
There are several risks like infection, bleeding, injury to the surrounding tissues, leakage from the joints between the stomach and the bowel, narrowing of the join between the stomach and the bowel, chest infection, clot on the leg, clot on the lung and small risk of death.
There is also a risk of nutritional deficiencies unless you take the vitamins and mineral supplements. There is also a risk that you might lose much weight or might put the weight back on unless you make lifelong changes to your diet and physical activity habits.
What are the issues with the gastric bypass.
The gastric bypass has a lifelong risk of ulcers especially among patients who smoke, who take anti-inflammatories (like Ibuprofen) or who have a large gastric pouch.
The bypass has some lifelong risk of bowel blockage (obstruction) because of internal herniation. If detected late, internal herniation might result in bowel ischaemia (reduced blood supply to the bowel).
This operation might not be the right operation if the patient has some bowel conditions like inflammatory bowel disease or how have extensive scar tissue (adhesions).
It might be more appropriate to do the gastric bypass as a second stage procedure (after another bariatric operation) in people affected by very severe obesity.
What to expect after Roux-en-y Gastric bypass?
The operation takes about one and a half to two and a half hours to perform. After surgery, you will go to the recovery room and then to the ward. You will stay in the hospital one night and you are highly likely to be discharged home the day after your surgery.
On the day of surgery, I will allow you to drink clear fluids (water/flavoured water, peppermint tea). On the morning after the surgery, I will allow you to drink any type of fluid that you would like (we advise avoiding sugary drinks after the surgery). Surgeons differ in the timing of the introduction of food to their patients after the surgery. However, I allow my patients to have a pureed diet 24 hours after having a sleeve gastrectomy. People get confused about what pureed diet is. My definition of pureed food is any food that has a consistency that is like the consistency of yoghurt. I ask my patients to stay on a pureed diet for four weeks after the surgery. After four weeks they can move to a soft diet. A soft diet has a consistency like the consistency of mashed potato. They cannot eat solid food for six weeks after the surgery.
After the operation, I encourage people to start physical activity very quickly! On the day of surgery, the nursing team ask patients to walk around the room and go to the toilet on their own if that is possible. I encourage my patients to walk and increase their physical activity very quickly after surgery if they adhere to the following three restrictions. They should not lift up heavy objects (anything heavier than 10 pounds) for six weeks after the operation. They should not swim or have a bath for two weeks. They should not drive until they are able to do an emergency stop without pain (this normally takes about 10 days to two weeks). If a patient wishes to go for a run the day after discharge, and they feel up to it, I might not have objections!
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