Roux-en-Y Gastric Bypass is a type of restrictive as well as malabsorptive surgery. Physically, it restricts food intake; portions sizes after the Roux-en-Y Gastric Bypass are much reduced with an early feeling of fullness. While the majority of the reduction in a patient’s calorie intake is attributable to the restriction caused by the Roux-en-Y Gastric Bypass, there is also an element of malabsorption of fat, which occurs because of the bypass of the first portion of the small intestine.
Roux-en-Y Gastric Bypass is a surgical procedure that can be performed by a minimally invasive surgical method. Usually 4-5 small cuts of 0.5 – 1 cm are made on the abdomen. The Roux-en-Y Gastric Bypass is then performed Laparoscopically or Robotically, using highly advanced technology to make it safe. In the first step of a Roux-en-Y Gastric Bypass, the stomach is divided into 2 parts – a small functional stomach pouch and a larger excluded stomach. The volume of the stomach pouch after RYGB is between 30 and 50 ml. In the second step, the upper portion of the small intestine is divided into 2 segments, and the lower segment (alimentary limb, green in the picture) is then connected to the small stomach pouch (Gastrojejunostomy). This establishes Gastrointestinal continuity, i.e. this is the new route that food must follow. In the third step of the Roux-en-Y Gastric Bypass, the 1st part of the byspassed small intestine (BP limb, pink in the picture) is reconnected to a point on the second segment (Jejunujejunostomy), so that bile and pancreatic juices which are essential for digestion meet the food eaten at a much later point than normal.
In a Roux-en-Y Gastric Bypass, the amount of food you can eat in one sitting is reduced because of the small stomach pouch capacity. Because of this, the brain utilises the fat stored in your body for its energy needs. This burns the excess fat in your body, thus helping you lose weight. Also, in a Roux-en-Y Gastric Bypass, the production of the hunger hormone Ghrelin is markedly reduced, since the fundus of the stomach is excluded. Because of this, you do not feel hungry all the time, and are satisfied with the small amount of food you eat without feeling tired or weak. The malabsorptive effect because of the bypass of the small intestine in a Roux-en-Y Gastric Bypass causes markedly reduced absorption of fats from your intestine. This further adds to the weight loss effect. Roux-en-Y Gastric Bypass reduces a patient’s appetite. The mechanism by which this occurs is not fully understood, but is related to a change in the normal gut hormonal patterns. Bypassing the first part of a patient’s small intestine affects the production of hormones that control appetite. After Roux-en-Y Gastric Bypass most patients feel far less hungry, often forgetting to eat.
There is immense medical evidence to conclusively prove that Roux-en-Y Gastric Bypass can help with complete reversal of Type II Diabetes Mellitus in 85-90% of patients for 10-15 years. This means, that almost 90% of patients who were diabetic can STOP all medications for Diabetes after undergoing a Roux-en-Y Gastric Bypass. This occurs due to beneficial effect of the bypass of the small intestine that causes changes in the hormonal axis of the body for better control of blood sugar levels. In addition, after a Roux-en-Y Gastric Bypass, marked improvement is seen in many other medical problems which are caused due to obesity, such as hypertension, sleep apnea, Hypothyroidism, Osteoarthritis, PCOS, etc. A reduction in body weight is the key mechanism behind this improvement.
Anybody with a BMI of > 37.5 kg/m2 (Asian population) or >32 kg/m2 with medical diseases can undergo a Roux-en-Y Gastric Bypass. It is very beneficial in: • Patients with Diabetes Mellitus, Hypertension and other obesity – related diseases • Sweet eaters • Patients with heartburn (GERD/ acidity)
The amount of weight loss you achieve differs with every weight loss procedure. Typically, in medical literature, it has been reported that patients lose upto 70% of their excess body weight after a Roux-en-Y Gastric Bypass. This is adequate to maintain a healthy lifestyle without any medical diseases. However, patients who stick to a regular exercise pattern post weight loss surgery may achieve even greater amounts of weight loss.
Weight loss after any weight loss procedure is a gradual process. It starts within the first week of surgery, and continues for upto 10-12 months post weight loss surgery. By this point, most of your excess weight is lost, and you become fitter and healthier.
This is unlikely after a Roux-en-Y Gastric Bypass , since the body knows when it has lost the excess weight required to be healthy, and the weight loss stops. However, in rare cases, if the malabsorptive effect is too strong, excessive weight may be lost. In such cases, complete surgical reversal of the procedure is required.
Any surgery performed on the stomach or intestines has certain risks. Some of the possible dreaded complications of Roux-en-Y Gastric Bypass are:
1. Staple line leak/ Anastomotic leak – this usually occurs along the staple line or at the joint between the stomach and small intestine in Roux-en-Y Gastric Bypass. It may occur due to a technical fault the mechanical stapler, or due to poor blood supply to the new joint. In most cases, this leads to a localized area of fluid collection, which can be managed with antibiotics. In certain cases, a second surgery maybe needed to drain the fluid leaking from the joint. In either case, it prolongs the hospital stay. Fortunately, the incidence of a leak is 1 in a 1000 patients, making it rare. We ALWAYS test for a mechanical fault in the staple line by doing a Methylene Blue dye test on the operating table, so that a defect, if any, can be repaired immediately.
2. Deep Vein Thrombosis – This is a complication that can occur in any morbidly obese patient irrespective of whether they undergo a surgery or not. In this condition, blood in the deep veins of your calves can form clots. These clots may then dislodge from the veins, reaching the lungs and leading to Pulmonary embolism, which if not treated quickly may be fatal. It is treated by giving injectable anticoagulant medications (blood thinners) to the patient. The incidence of DVT is also rare, being seen in 1 patient out of a 1000. We ALWAYS give preventive injectable anticoagulants to the patient for 28 days after a Roux-en-Y Gastric Bypass. In addition, if the patient is well mobilized and is walking daily as advised after the surgery, the chances of DVT are very remote.
3. Bleeding – This is again a complication that can occur with any surgery in any patient. All possible sites of bleeding are checked at the end of surgery, and it is ensured that bleeding does not occur in the post-operative period.
4. Dumping syndrome - Dumping usually occurs a few weeks after Roux-en-Y Gastric Bypass, due to poor food choices. It is related to the ingestion of refined sugars, high glycemic carbohydrates, dairy products, some fats, and fried foods. These foods rapidly empty from the gastric pouch into the small intestine, which triggers a cascade of gastrointestinal changes. This should be discussed in detail with your surgeon. It can usually be managed with good dietary habits.
Some patients have nutritional deficiencies post Roux-en-Y Gastric Bypass, but these are easily preventable by taking regular multivitamin and multi mineral supplements as prescribed soon after surgery. These supplements may have to be taken lifelong, since the malabsorptive effect of the weight loss surgery persists for life
Yes, Roux-en-Y Gastric Bypass is a completely reversible procedure. This requires a second surgery, which can again be performed by minimally invasive techniques (laparoscopically or robotically). It is a very complex surgery requiring a high degree of surgical skill and intensive post-operative care.
• Roux-en-Y Gastric Bypass is a good operation for patients who failed restrictive procedures like balloon, banding and sleeve gastrectomies , causing 60-70 % excess weight loss.
• Roux-en-Y Gastric Bypass has been found to have a 85-90% remission rate for Diabetes Mellitus for upto 15 years after surgery.
• Roux-en-Y Gastric Bypass is a reversible procedure unlike the sleeve gastrectomy.
• Frequent passage of stools in some.
• Over-eating may cause abdominal discomfort and vomiting in some.
• Life-time vitamin and mineral supplements are usually needed after surgery.
• Conventional upper gastroscopy of duodenum and remnant stomach is not possible.
The chances of you regaining weight after a RYGB are little lower than with a Sleeve Gastrectomy. However, maintenance of a healthy lifestyle is of the utmost importance after any type of weight loss surgery. Having good control over your diet, i.e. eating protein rich food, and exercising regualrly will help ensure that you do not regain weight after the surgery. Outcome depends on long-term adherence to diet and lifestyle changes and requires frequent monitoring and adjustments to achieve ultimate weight loss.
Follow up with your doctor and dietician is the most critical part after any weight loss surgery. With every follow up, certain laboratory tests are needed, which help to gauge the body’s response to the weight loss. At every follow up, we assess you to ensure that you are on track with your weight loss, and motivate you to stick to a healthy lifestyle. This has been found in many studies across the world to be the most important in achieving long-term weight loss.
In this procedure, a GaBP Ring Autolock™ is added above the joint between the stomach and intestine. This helps in maintenance of weight loss in the long term.
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