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According to the American
Society for Bariatric Surgery (ASBS) and the United States
National Institutes of Health (NIH), Roux-en-Y gastric bypass is
the current gold standard procedure for modern weight loss
surgery. It is also one of the most frequently performed weight
loss procedures in the United States. Most of the stomach and a
variable length of small intestine are bypassed thus combining
both restrictive and malabsorptive components.
What
is Gastric Bypass Roux-en-Y ?
Gastric
Bypass Roux-en-Y reduces the capacity of the stomach by creating
a small stomach pouch. The small space holds only one ounce of
fluid. The procedure also constructs a tiny stomach outlet,
which slows the speed by which food leaves your stomach. So you
will feel full after eating a small amount and you will stay
satisfied for a long time.
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Staples
are used to create a small (15 to 20cc) stomach pouch across
the top part of the stomach (just below the point where
esophagus joins). |
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The rest
of the stomach is not removed, but is stapled completely
shut and divided from the stomach pouch. Food will not enter
this part of the stomach (which is bypassed). |
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In order
for the food to pass into the small intestine from the
pouch, the small intestine (jejunum) is divided 50 cms
beyond the duodenum, brought up, and connected to the newly
formed stomach pouch. The opening from the pouch to the
small intestine is small so as to delay emptying of the
pouch. |
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The newly
formed pouch empties directly into the lower portion of the
intestine bypassing calorie absorption. |
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The other
end of the jejunum is connected into the side of the pouch
limb of the intestine 75 to 150 cms away from its cut end
(creating the "Y" shape that gives the technique
its name). |
How
does the Gastric Bypass surgery work ?
It
is easier to understand how the gastric bypass surgery works
once you understand how the digestive system works. The mouth
and teeth are used to grind and chew our foods before
swallowing.
When we swallow, food passes through the
esophagus into the stomach. It is in the stomach where
preliminary digestion takes place. This occurs in two ways.
First, the stomach helps to grind the food to paste. Also
present in the stomach are digestive juices and acid. These
digestive juices begin “preliminary” digestion of
carbohydrates, proteins and fats turning the food into a paste
called chyme. The chyme then passes slowly into the small
intestine.
In the small intestine foods are fully
digested. Small particles of food called sugars, amino acids and
triglycerides are then absorbed across the intestinal wall into
the blood stream. Vitamins and minerals are also absorbed from
the small intestine. Undigested food, such as fiber and other
body waste products, then pass along to the large intestine
where they are made into solid waste and excreted from the body.
Gastric
Bypass surgery is designed to help with weight loss both by
restrictive and malabsorptive means. The small stomach pouch
initially will only hold one to two ounces of food at a time.
Once the pouch is full, it takes about ten or more minutes for
food to pass through to the small intestine. This gives a
feeling of early satiety after consuming small amount of food It
will take, on average, 30 to 45 minutes to eat a meal consisting
of two ounces of meat and one-fourth cup each of a starch,
vegetable, and fruit. Therefore one stays satisfied for a longer
time after meal.
In addition, the pouch is now too
small to help grind foods for you. Only small amounts of
digestive juices will be present to turn foods into a paste.
This means you will have to thoroughly chew all foods to a baby
food consistency before swallowing. Otherwise, the food will be
too bulky to pass from the pouch through the opening to the
small intestine. Failure to chew foods will result in pain or
discomfort and possibly vomiting.
The time it takes to
chew foods thoroughly and the limited space in the stomach pouch
reduces the amount of food you are able to consume at a meal
time. This will cut down on the amount of calories you consume
at a given meal, which in turn will help with weight loss.
With
the intestinal tract sewn directly to the stomach pouch, liquid
food will now flow uncontrolled from the stomach to the
intestine. Sugar, which is already in its fully digested form,
is rapidly absorbed across the intestinal tract into the blood
stream. If the food you eat contains sugar, you will experience
"dumping syndrome". You body's response to consuming
too much sugar is to break into a cold sweat, nausea, and
possibly vomiting, diarrhea, and overall weakness. This feeling
will last for approximately 20-30 minutes. Once this has
happened, most people are careful not to consume foods high in
sugar. Foods high in sugar are also high in calories. Many foods
high in sugar are also high in fat, therefore, high in calories.
Eliminating sweets and fats from your diet will help with
weight loss.
Since gastric Bypass surgery involves
reshaping the stomach and small intestine, the food in the
gastric pouch and food channel cannot mix with digestive juices
till the junction of the digestive juice channel. Therefore
little digestion occurs in the stomach and the food channel
thereby limiting absorption of calories and nutrients.
In
review, the Gastric Bypass surgery simply forces the same
behavior modification that are found in any sensible diet
program: eat three meals a day, eat small portions, eat more
slowly, and avoid high calorie foods and when satiety is
reached, stop eating. The difference being, with surgery, after
the first 20 to 30 pounds of weight loss, you cannot decide to
forget about dieting. Surgery is permanent. Therefore, unlike
other methods of weight reduction, because of the surgical
modifications made to your digestive system, you stay with the
diet for the rest of your life. “Dumping syndrome”
helps alleviate the “craving” for sweets and desserts.
Laparoscopic
Gastric Bypass Roux-en-Y
Laparoscopic
Roux-en-Y gastric bypass is identical to the traditional gastric
bypass except that instead of being performed through an
incision extending from the lowest aspect of the breastbone
(xiphoid process) to below the umbilicus (navel), it is
performed through several smaller incisions each measuring about
an inch or less in length. A laparoscope connected to a video
camera is inserted into the abdominal cavity and the inside of
the abdominal cavity is visualized on video monitors. Long thin
surgical instruments and especially designed staplers are
inserted through additional small incisions; the surgeon
performs the surgery by watching the video monitor.
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| Incision
of Open Gastric Bypass |
Ports
of Laproscopic Gastric Bypass |
The
advantages to performing the Gastric Bypass Laparoscopically are
that it yields cosmetically superior results and the recovery is
faster. Some long-term problems of open surgery, such as
incisional hernias and wound infections, also occur less
frequently. However, sometimes because of difficulty in
visualization, the operation must be converted to an open
procedure in order to complete the operation safely. This
decision, of course, is made during the course of the operation
while the patient is under anesthesia, so the patient must be
aware of this possibility before the surgery starts. Another
disadvantage is that the incidence of leakage from the surgical
staple lines may be more common in the postoperative period.
Leakage from the staple line is a serious complication and often
necessitates additional surgery, usually using a traditional
incision, and prolonged hospitalization, and sometimes even
death.
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