According to the American Society for Metabolic and Bariatric Surgery and the National Institutes of Health, Roux-en-Y gastric bypass is the current gold standard procedure for weight loss surgery. In the U.S., over 200,000 gastric bypass procedures will be performed in 2011, far outnumbering the adjustable gastric band, sleeve gastrectomy and other weight loss procedures. To date we have performed over 2,500 gastric bypass procedures at MUSC.
Roux-en-Y gastric bypass (RGB), is both restrictive and malabsorbtive. The stomach is stapled and divided to create a small pouch (about the size of a golf ball) that dramatically restricts portion size and gives the feeling of fullness after just a few bites of food. A limb of small intestine, 150 cms long (the “Roux limb”) is then connected to the stomach pouch so food can travel down the intestine where it meets with the “biliary limb” which drains the lower (excluded) stomach, the duodenum and upper small intestine. This limb carries digestive juices. Where these 2 limbs meet, digestion begins. This is the malabsorbtive part of the gastric bypass operation and because the upper part of the intestine is bypassed by food, less calories are absorbed.
The Roux-en-Y gastric bypass surgery is usually performed laparoscopically. This means that small incisions are used to insert small thin plastic tubes into the abdomen. A video camera with a long lens is passed through one of these tubes and long instruments and staplers are passed through the rest. The surgeons perform the surgery while looking at images from the camera inside the abdomen projected onto high definition monitors at the head of the OR table. We try to perform laparoscopic surgery on all patients nowadays. We have no weight limit and have completed gastric bypass on patients with very high BMI. Occasionally it is necessary to perform the surgery through an open incision. Usually this is because of previous operations which make the laparoscopic approach impossible. The laparoscopic approach to gastric bypass reduces the amount of post operative pain the length of hospital stay, the amount of scarring, and results in quicker recovery compared to an open procedure.
As with all surgery, complications are a possibility. Statistics indicate that about one patient in 200 will not survive the surgery or the immediate postoperative period. This number is highly variable depending on how "high risk" you are as a patient and also on the experience of the team taking care of you. In our experience at MUSC, much like other large programs, the most common causes of death are pulmonary embolus (blood clot to the lungs) and peritonitis (infection in the abdomen) from a leak from any of the hook-ups between pieces of intestine or to the pouch. Most of the other complications occur when you have left the hospital following gastric bypass surgery, but are not life threatening. We handle most of these in the clinic or over the phone.
Wound infection: may require long term treatment (sometimes months) with dressing changes, but almost always heal on their own without further surgery.
Incisional hernia: a weakness or defect in the incision after an open operation that may allow intestine or tissue to bulge through; may be caused by trying to do too much too soon after your gastric bypass surgery. You can help prevent this complication by following our suggestions (no heavy lifting, no heavy housework, etc. for at least six weeks, or as prescribed by the surgeon after surgery). The only treatment is surgical repair.
Stomal stenosis: too tight an opening between the stomach and the intestinal "hook-up". This can be treated by inserting a lighted tube through the mouth to the tight area and stretching it with a balloon.
Stomal ulcer: usually heal with an anti-ulcer medication. To help prevent ulcers after surgery, we give all patients a prescription for Pepcid for one month or similar anti-ulcer medication.
Gallstones: prior to your surgery, you will have an ultrasound of your gallbladder to see if you have gallstones. If you have any stones or gallbladder disease, your gallbladder will be removed at the same time as the gastric bypass surgery. However, if you have a healthy gallbladder, it will be left in place. You will then be treated with a gallstone prevention medication called Actigall for six months.
Blood clots: a blood clot to the lungs, or pulmonary embolism, a possible complication after any surgery, can be very serious. For this reason, we take extra steps to prevent this problem.
Leak: a leak from any of the "hook-ups" is one of the most serious complications. Although rare (1-2%), this complication can be extremely serious and potentially fatal. For this reason, some patients are checked for a leak before leaving the hospital. This is done by an upper GI series (an x-ray with barium). All patients have an upper GI series after a laparoscopic gastric bypass. If a leak occurs, emergency surgery may be necessary.
Long term complications: may include vitamin B12 deficiency (having too little B12 in your body), calcium deficiency (which increases risk of brittle bones or osteoporosis), and iron deficiency anemia. To minimize the potential for these problems, we insist that all patients take lifetime daily vitamin supplements (multivitamin, B12 and calcium) and iron (for menstruating females). We also require lifetime follow-up with the surgeon, including yearly blood work to identify problems.
Inadequate weight loss: another possible complication, is usually preventable and treatable with patient compliance (following the guidelines we give you). We highly recommend that all patients eliminate sweets and high fat, high calorie foods from the diet. This complication may also be caused by a "staple disruption" (a break in the staples dividing the stomach pouch and the rest of the stomach). This problem may allow the patient to eat larger quantities of food, potentially causing weight gain or inadequate weight loss.
Bariatric surgery has been performed for many decades. For many of those years, the surgery was performed as an open procedure. An open procedure means bariatric surgeons create a long incision, or cut, opening up the patient. As medical technology evolved, laparoscopic or minimally invasive surgery became a possibility. With laparoscopic surgery, bariatric surgeons create small incisions. Both approaches to bariatric surgery have similar success rates in reducing excess weight and improving or resolving co-morbidities.
Most bariatric surgeons will perform bariatric surgery using the laparoscopic method. However, this is a decision that you and your doctor and/or bariatric surgeon must make together. An important question for patient to ask is: How many minimally invasive versus open procedures has the surgeon performed? Read below to learn more about both procedures.
Open bariatric surgery involves creating a long incision line to open the abdomen and operating with "traditional” medical instruments. Because of the incision, the patient’s stay in the hospital will be several days longer than with minimally invasive bariatric surgery. The recovery time is also much longer with open bariatric surgery. Patients will need to heal for weeks before returning to work and regular physical activities. With a longer wound, there is more of a chance of wound complications such as infections and hernias. A long incision leads to a long scar. In some cases, the open method is necessary due to some patient-specific risks.
A laparoscopic operation involves the bariatric surgeon making several small incisions for different medical devices to be used. There are, on average, four to six ports created. The devices, including a small video camera, are inserted through the ports. Surgeons use a monitor to perform the procedure. Most laparoscopic surgeons believe this gives them a better view and excellent access to key body parts. Many patients are able to recover from the surgery in a fraction of the time that open procedures require. In fact, some return to work in little more than a week, and many are able to speed up their weight loss and quickly return to physical activity. Patients will have very small scars. There is also a lower chance of wound complications such as infection and hernia.
Laparoscopic and open procedures for bariatric surgery both produce similar weight loss. However, not all patients are candidates for the laparoscopic approach to bariatric surgery, just as all bariatric surgeons are not trained to perform this less-invasive method. The American Society for Metabolic and Bariatric Surgery recommends that laparoscopic bariatric surgery should be performed only by bariatric surgeons who are experienced in both laparoscopic and open bariatric procedures. Here at MUSC our bariatric surgeons have extensive experience with both laparoscopic and open procedures.