GASTRIC BYPASS

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[ General Information About Bariatric Surgery ]

The so called Roux-en-Y gastric bypass (RGB) has been the most commonly performed operation for weight loss all over world. It is considered as the gold standard among all bariatric procedures.  A Roux-en-Y stomach bypass can be performed laparoscopically or by using open surgery, and has three basic variants, depending on the length of intestine bypassed. Proximal RGB involves very little malabsorbtion of calories and nutrients. Medial RGB causes moderate malabsorbtion, while Distal RGB causes significant malabsorbtion. In comparison with Biliopancreatic Diversion (BPD) or Biliopancreatic Diversion with Duodenal Switch (BPD/DS), during Roux-en-Y the bariatric surgeon does not remove the unused part of the stomach. Instead the stomach is transected, using gastric staples, into a small upper section (the pouch) and a larger lower section.

Illustration of a Roux – en – Y Gastric Bypass

Compared to BPD and BPD/DS, Roux-en-Y bypass operations are more restrictive (patients can eat less), but less malabsorptive (decreased chances of nutritional deficiency). Lastly, RGB is reversible, as the stomach is divided or partitioned - unlike the other bypass procedures where the unused stomach is surgically removed.(6)

Potential complications of gastric bypass surgery (7,9-11)

Complications resulting from gastric bypass surgery can be segmented into two groups:

1. Complications that relate to abdominal or laparoscopic surgery in general and
2. Coplication that relate  specifically to gastric bypass surgery.

Complications of abdominal surgery

Infection
Infection of the incisions or of the inside of the abdomen (peritonitis, abscess) may occur, due to release of bacteria from the bowel during the operation. Nosocomial infection (infections acquired in hospitals), such as pneumonia, bladder or kidney infections, and sepsis (bloodborne infection) are also possible. Effective short-term use of antibiotics and encouragement of activity within a few hours after surgery, can decrease the risks of infections.

Blood loss
Surgery can leed to loss of excessive blood. Transfusions may be needed, or a re-operation is sometimes necessary to identify and stop the source of bleeding.

Incisional Hernia
An incisional hernia occurs when a surgical incision does not heal properly; the muscles of the abdomen separate and allow protrusion of a sac-like membrane, which may contain bowel or other abdominal contents. Today, the risk of abdominal wall hernia is markedly decreased in laparoscopic surgery.

Bowel obstruction
Usually an operation is necessary to correct this problem.

Venous thrombo-embolism
A blood clot, which may form in the veins of the legs due to post surgical inactivity and subsequently breaks free and floats to the lungs is called a pulmonary embolus.  This is considered a severe postsurgical complication. Commonly, anti-coagulants (heparin) are administered before surgery as well as for a certain period after surgery, to decrease the probability of this complication.

Complications of gastric bypass

Anastomotic leakage
An anastomosis is a surgical connection between the stomach and bowel, or between two parts of the bowel. Leakage of an anastomosis can occur in about 2% of gastric bypass procedures, usually at the stomach-bowel connection. Sometimes leakage can be treated conservatively, and sometimes it will require immediate re-operation. It is usually safer to re-operate if an infection cannot be definitely controlled immediately.

Anastomotic stricture
This late complication describes a narrowing of the anastomosis, making it difficult for food to pass through it.  Gastrointestinal endoscopy is performed and a balloon is inflated at the site of the narrowing. Sometimes this manipulation may have to be performed more than once to achieve lasting a correction.

Dumping syndrome
Normally, a valve at the lower end of the stomach regulates the release of food into the bowel. When the Gastric Bypass patient eats  foods with high contents of simple sugars, the sugar passes rapidly into the bowel, where it gives rise to a physiological reaction called dumping syndrome. The patient usually has to lie down, and could be very uncomfortable for about 30 to 45 minutes. It may be followed by diarrhea.

Nutritional deficiencies

Hyperparathyroidism , due to inadequate absorption of calcium, may occur. Most patients can achieve adequate calcium absorption by supplementation with vitamin D and calcium citrate.
Iron is often seriously deficient, particularly in menstruating females, and must be supplemented.
Protein malnutrition is a serious risk. Some patients suffer troublesome vomiting after surgery, until their GI tract adjusts to the changes. Many patients require protein supplementation during the early phases of rapid weight loss, to prevent excessive loss of muscle mass.  Today, this is easy to manage, as high quality protein supplements are available at any grocery store.
Vitamin deficiency my also develop. Adequate supplementation should be given
 

Gastric Bypass Surgery in Germany

Or center for bariatric surgery is a leading institution with an established track record with this procedure. The bariatric surgeons are able to assess the risks and benefits of each procedure together with you and will, based on your personal requirements, suggest a procedure that is most suitable for you. Please contact us for more information.

References:

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8. Sjöström L, Lindroos AK, Peltonen M, Torgerson J, Bouchard C, Carlsson B, Dahlgren S, Larsson B, Narbro K, Sjöström CD, Sullivan M, Wedel H. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med 2004;351:2683–93.
9. Buchwald H.  International symposium on gastric banding. Supplement to Surgery for Obesity and Related Diseases.2008. Cambridge, MA: Elsevier; 4:35;pp 71
10. Himpens J, Dapri G, Cadiere GB.A prospective randomized study between laparoscopic gastric banding and laparoscopic isolated sleeve gastrectomy: results after 1 and 3 years. Obes Surg 2006;16:1450–6.
11. Kreft JS, Montebelo J, Fogaca KC, Rasere I, Oliveira MR.Gastric bypass: post-operative complications in individuals with and without preoperative dietary guidance. Journal of Evaluation in Clinical Practice2008;14:169–71