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gastric bypass surgery; Roux-en-Y gastric bypass

Also see bariatric surgery. Indications: - morbid obesity; BMI > 40 - BMI > 35 with serious obesity-related comorbidities [4] Procedure: 1) combines gastric restriction with diminished absorption 2) stapling the cardia of the stomach creates a 20-30 mL pouch; ref [4] suggests pouch size of 7-10 mL 3) the jejunum is divided distal to the ligament of Treitz with the distal end anastomosed to the upper stomach; duodenum & lower part of stomach bypassed 4) hospital stay typically 3-4 days Laboratory: - twice a year for the first 2 years after gastric bypass, then yearly laboratory tesing consisting of: [4] - serum vitamin B12 - serum ferritin - serum folate - serum calcium - serum 25-OH vitamin D * also see ARUP consult [15] Complications: - complications 15% - abdominal pain is the most common post-operative complication [19] - 30 day major complications 5% (venous thromboembolism) - 30 day mortality 0.5% - stomal stenosis (manifested by nausea/vomiting) [4] - cholelithiasis [4] - nephrolithiasis [4]; calcium oxalate stones - stricture or ulceration - dumping syndrome - intestinal bacterial overgrowth [4] - trial of empiric antibiotics - increased risk of suicide [6,13]; overall rate low - nuritional deficiency - vitamin A deficiency in 10-50% & up to 61-69% with bilio- pancreatic diversion [4] - vitamin B12 deficiency [4] due to lack of intrinsic factor - folate deficiency, vitamin D deficiency, calcium deficiency, iron deficiency, copper deficiency [4,7] - other vitamin deficiencies including thiamine deficiency, pyridoxine deficiency, vitamin C deficiency, vitamin E deficiency, vitamin K deficiency, selenium deficiency & zinc deficiency less common [4] Management: - patients must consume < 800 kcal/day for 1st 12-18 months - diet 1000-1200 kcal/day (after 1st 12-18 months) in 3 small high-protein meals 3 times/day - avoid sugar, refined carbohydrates & fats to prevent dumping syndrome - avoiding refined carbohydrates more important than low-fat diet [18] - trial of emipiric antibiotics for intestinal bacterial overgrowth [4] - revision & reoperation much lower than for gastric banding (0.3% vs 17%) [6] Notes: - superior to gastric banding [2,6], but more complications [3] - twice as much weight loss as laparoscopic gastric banding, at the cost of more short-term complications & long-term hospitalizations [10] - sleeve gastrectomy more common than gastric bypass [8] - 60-70% excess weight loss [4]; - 35 kg vs 0-3 kg without surgery after 12 years in morbidly obese [13] - improvement in left ventricular hypertrophy [5] - GERD symptoms resolve in 63% of patients (contrast with sleeve gastrectomy) [9] - sustained benefits at 6 years, 10 years [12]; 12 years [13] - weight reduction (32% vs 16% for gastric banding) [6] - diminished risk of type 2 diabetes - 3% vs 26% without surgery after 12 years in morbidly obese [13] - 2/3 of patients with diabetes mellitus type 2 sustain at least partial remission (vs 1/4 for gastric banding) [6] - diminished risk of hypertension - diminished risk of lipodystrophy - improvements in dyslipidemia similar to gastric banding [6] - 5-year diabetes remission rate somewhat higher for gastric bypass than sleeve gastrectomy [16] - more weight loss with gastric bypass vs sleeve gastrectomy or adjustable gastric banding [14] - 30 day complications (reoperation, venous thromboembolism) more frwquent 5% vs < 3% for other procedures [14]

Specific

esophagocolic anastomosis; esophagocolostomy esophagojejunostomy

General

bariatric surgery surgical anastomosis

References

  1. Brolin RE Bariatric surgery and long-term control of morbid obesity. JAMA. 2002 Dec 11;288(22):2793-6. Review. PMID: 12472304
  2. Journal Watch 25(2):19, 2005 Weber M, Muller MK, Bucher T, Wildi S, Dindo D, Horber F, Hauser R, Clavien PA. Laparoscopic gastric bypass is superior to laparoscopic gastric banding for treatment of morbid obesity. Ann Surg. 2004 Dec;240(6):975-82; discussion 982-3. PMID: 15570203
  3. Nguyen NT et al A prospective randomized trial of laparoscopic gastric bypass versus laparoscopic adjustable gastric banding for the treatment of morbid obesity: Outcomes, quality of life, and costs. Ann Surg 2009 Oct; 250:631 PMID: 19730234
  4. Medical Knowledge Self Assessment Program (MKSAP) 15, 16, 17 American College of Physicians, Philadelphia 2009, 2012, 2015 - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  5. Owan T et al. Favorable changes in cardiac geometry and function following gastric bypass surgery: 2-year follow-up in the Utah Obesity Study. J Am Coll Cardiol 2011 Feb 8; 57:732. PMID: 21292133
  6. Adams TD et al Health Benefits of Gastric Bypass Surgery After 6 Years JAMA. 2012;308(11):1122-1131 PMID: 22990271 http://jama.jamanetwork.com/article.aspx?articleid=1360861 - Courcoulas AP Progress in Filling the Gaps in Bariatric Surgery JAMA. 2012;308(11):1160-1161 PMID: 22990275 http://jama.jamanetwork.com/article.aspx?articleid=1360844
  7. Juhasz-Pocsine K, Rudnicki SA, Archer RL, Harik SI. Neurologic complications of gastric bypass surgery for morbid obesity. Neurology. 2007 May 22;68(21):1843-50. PMID: 17515548
  8. Reames BN et al Changes in Bariatric Surgery Procedure Use in Michigan, 2006-2013. JAMA. 2014;312(9):959-961. PMID: 25182106
  9. DuPree CE et al. Laparoscopic sleeve gastrectomy in patients with preexisting gastroesophageal reflux disease. A National Analysis. JAMA Surg 2014 Feb 5 PMID: 24500799
  10. Arterburn D et al Comparative Effectiveness of Laparoscopic Adjustable Gastric Banding vs Laparoscopic Gastric Bypass. JAMA Surg. Published online October 29, 2014 PMID: 25353723 http://archsurg.jamanetwork.com/article.aspx?articleid=1919066 - Dimick JB, Finks JF The Beginning of the End for Laparoscopic Banding. JAMA Surg. Published online October 29, 2014 PMID: 25353359 http://archsurg.jamanetwork.com/article.aspx?articleid=1919064
  11. Machado JD, Campos CS, Lopes Dah Silva C et al Intestinal bacterial overgrowth after Roux-en-Y gastric bypass. Obes Surg. 2008 Jan;18(1):139-43. Epub 2007 Dec 14. PMID: 18080824
  12. Maciejewski ML, Arterburn DE, Van Scoyoc L et al Bariatric Surgery and Long-term Durability of Weight Loss. JAMA Surg. Published online August 31, 2016 PMID: 27579793 http://archsurg.jamanetwork.com/article.aspx?articleid=2546331 - Gould JC Myths Surrounding Bariatric Surgery. JAMA Surg. Published online August 31, 2016 PMID: 27579624 http://archsurg.jamanetwork.com/article.aspx?articleid=2546323
  13. Adams TD, Davidson LE, Litwin SE et al. Weight and metabolic outcomes 12 years after gastric bypass. N Engl J Med 2017 Sep 21; 377:1143 PMID: 28930514
  14. Arterburn D, Wellman R, Emiliano A et al Comparative Effectiveness and Safety of Bariatric Procedures for Weight Loss: A PCORnet Cohort Study. Ann Intern Med. 2018. Oct 30. PMID: 30383139 http://annals.org/aim/fullarticle/2711394/comparative-effectiveness-safety-bariatric-procedures-weight-loss-pcornet-cohort-study - Puzziferri N, Wolfe BM PCORnet Bariatric Surgery Outcomes: Strength in Numbers. Ann Intern Med. 2018. Oct 30. PMID: 30383123 http://annals.org/aim/article-abstract/2711441/pcornet-bariatric-surgery-outcomes-strength-numbers
  15. ARUP Consult: Gastric Bypass - Bariatric Surgery Nutritional Assessment The Physician's Guide to Laboratory Test Selection & Interpretation https://www.arupconsult.com/content/gastric-bypass
  16. Murphy R et al. Effect of banded Roux-en-Y gastric bypass versus sleeve gastrectomy on diabetes remission at 5 years among patients with obesity and type 2 diabetes: A blinded randomized clinical trial. Diabetes Care 2022 Jul; 45:1503. PMID: 35554515 PMCID: PMC9274222 Free PMC article https://diabetesjournals.org/care/article/45/7/1503/146925/Effect-of-Banded-Roux-en-Y-Gastric-Bypass-Versus
  17. Hammer HF. Medical complications of bariatric surgery: focus on malabsorption and dumping syndrome. Dig Dis. 2012;30(2):182-6. PMID: 22722436 Review.
  18. NEJM Knowledge+ Endocrinology
  19. Fry BT, Finks JF. Abdominal Pain After Roux-en-Y Gastric Bypass. A Review. JAMA Surg. 2023;158(10):1096-1102. PMID: 37531117 https://jamanetwork.com/journals/jamasurgery/fullarticle/2808064