Maxwell Kruse 3/23/14 ENG202C Technical Definition and Description

Roux-En-Y Gastric Bypass: A Surgical Solution to Morbid Obesity

Morbid obesity is a medical condition that poses severe health risks including type 2 diabetes, hypertension, heart disease, stroke, asthma, osteoarthritis, and many others. Sadly, millions of Americans suffer from this condition, and the number of morbidly obese Americans has increased by over 350% since 1980. A person is considered morbidly obese if they are 100 lbs heavier than their ideal weight, or if they have a body mass index (BMI) greater than 40. Unfortunately, morbidly obese patients struggle to lose weight through diet and exercise because the excess weight makes even basic tasks such as walking very difficult. For morbidly obese patients, bariatric surgery (weight loss surgery) is often necessary for an improved quality of life. Roux-en-Y gastric bypass (RYGB) is the most common form of bariatric surgery preformed in the United States, and is often prescribed as a treatment for patients struggling with morbid obesity.

Roux-En-Y Procedure Description

Roux-En-Y gastric bypass is a surgical procedure that reduces the size of the stomach and reorganizes the digestive system so that food bypasses the first part of the small intestine. Today, gastric bypass is typically carried out as a laproscopic surgery rather than an open surgery. The surgeon makes about 4-6 small incisions and completes the surgery by inserting a tiny video camera known as a laproscope into the abdomen. This is advantageous because it eliminates the need for a larger, more invasive incision in the abdomen. As a result, laproscopic gastric bypass produces smaller scars, has fewer complications, and provides a faster recovery time than traditional open surgery. During the first phase of the RYGP procedure, the surgeon staples off a small portion of the stomach. This essentially creates a new smaller stomach called the gastric pouch, which can be seen in the Figure 2 below. The gastric pouch is about the size of an egg, and typically can only hold about 1 ounce of food.

Figure 1: Incision Types for Surgery

Next, the surgeon attaches this gastric pouch directly to a Y-shaped portion of the lower small intestine known as the jejunum. As you can see in Figure 2, attaching this gastric pouch directly to the jejunum creates a pathway for food to bypass the majority of the stomach and the first part of the small intestine, which is called the duodenum. It should be noted that the bypassed portions of the stomach and duodenum are still present in the digestive system after the procedure. This is important because it allows digestive juices required for the breakdown of food to continue to flow from the bypassed section into the jejunum to aid in digestion.

How Does Gastric Bypass Produce Weight Loss?

To understand why Roux-En-Y gastric bypass is effective in producing weight loss, you first must understand what occurs in a typical digestive system. A normal digestive tract is shown on the left side of Figure 2 below. In normal digestion, food is first stored and broken down into smaller molecules in the stomach. The food, now known as chyme, then enters the duodenum of the small intestine. The small intestine is where 95% of all nutrients are actually absorbed into the body for use. This means that when we eat in excess, 95% of the fat, carbohydrates, and proteins we ingest are absorbed while traveling through the small intestine; the excess nutrients absorbed are then converted to fat and contribute to weight gain. The bypass created during RYGP is effective in producing weight loss because it moderates caloric intake in two ways; it is both a restrictive and a malabsorptive procedure. First, reducing the size of the stomach limits the amount of food patients can consume. This causes patients to feel full more quickly, thus preventing them from consuming large meals. In addition, bypassing the duodenum reduces the fraction of fat, protein, and carbohydrates that can be absorbed with each meal. By attaching the gastric pouch directly to the jejunum, this surgery effectively reduces the length of the small intestine; this is how the procedure limits the absorptive capacity of the digestive system. Ultimately, RYGP reduces both the physical amount of food patients can consume, and also reduces the fraction of food that can be absorbed by their bodies during each meal. This two-fold weight loss measure quickly leads to weight reduction in morbidly obese patients.
Before RYGP After RYGP

Figure 2: Roux-En-Y Gastric Bypass Procedure

Risks of Procedure
Although RYGP is very effective, it is a major surgical procedure. As with any surgical procedure, there are risks associated with it including: internal bleeding, infection, blood clots, heart attack and stroke. There are also some long term risks that are specific to the RYGP procedure including: Malnutrition After a gastric bypass surgery patients must make necessary, life-long changes to their diet to accommodate their new digestive system. Patients must avoid foods high and simple carbohydrates, and also have to eat adequate amounts of protein. Additionally, patients have to take daily multivitamins and mineral supplements to compensate for their reduced capacity to absorb nutrients. If patients do not take prescribed vitamins daily, they may suffer from malnutrition due to the reduced capacity of their digestive tract to absorb essential nutrients. Ulcers 2% to 7% of patients develop ulcers in the gastric pouch. Staple-line failure of the gastric pouch If patients do not follow the prescribed physical activity regimen and diet plan after RYGB, this sometimes results in issues with the gastric pouch. It is possible for the pouch to become distended, and also for sutures to fail; both of these conditions require a revisional surgery to be corrected. Vomiting - Patients will find that they regurgitate excess food after eating more than the gastric pouch can hold. Dumping Syndrome This is a condition where food and digestive fluids move into the small intestine too rapidly. Dumping results in vomiting, nausea, dehydration, profuse sweating, and rapid heart rate.

Efficacy of Roux-En-Y Gastric Bypass

RYGP is a very effective weight loss procedure, which is why it is the number one bariatric surgery recommended by the National Institutes of Health. In addition to having some of the most favorable weight loss results, studies show that RYGB is the most durable, long lasting bariatric procedure. On average, patients lose about 10-20 lbs with in the first year after surgery, and many experience a 45-85% reduction in their weight after 2 years. This weight loss drastically improves mobility, and enhances the patients ability to exercise. Over the long term this weight loss will improve any previous medical conditions such as hypertension, high cholesterol, asthma, and diabetes. A typical RYGP patient will enjoy a significant enhancement in their quality of life, and will also have an increased life expectancy. Although there are considerable risks associated with this procedure, the success rates of RYGB are high, and mortality rates are only 1-2% (typically due to surgical complications). For morbidly obese patients, the benefits of this bariatric procedure significantly outweigh the potential complications; the surgery poses fewer long-term risks to their health than remaining at their current weight does. This is why Roux-En-Y gastric bypass has become the gold standard weight loss surgery in the U.S. and is the recommended treatment for morbid obesity.

Works Cited "Gastric bypass surgery: MedlinePlus Medical Encyclopedia." U.S National Library of Medicine. U.S. National Library of Medicine, n.d. Web. 26 Mar. 2014. <http://www.nlm.nih.gov/medlineplus/ency/article/007199.htm>. "Massachusetts General Hospital | Digestive Healthcare Center." Roux-en-Y Gastric Bypass. N.p., n.d. Web. 26 Mar. 2014. <http://www.massgeneral.org/digestive/services/procedure.aspx?id=2301>. "Riverside Surgical & Weight Loss Center, llc." Laparoscopic Gastric Bypass. N.p., n.d. Web. 26 Mar. 2014. <http://www.riversidesurgicalweightloss.com/weight-losssurgery/laparoscopic-gastric-bypass/>. "Stock Photos: Roux-en-Y Gastric Bypass surgery." Dreamstime. N.p., n.d. Web. 26 Mar. 2014. <http://www.dreamstime.com/stock-photos-roux-en-y-gastric-bypass-surgeryimage23018753>. "What is Morbid Obesity?." What is Morbid Obesity. N.p., n.d. Web. 24 Mar. 2014. <http://www.urmc.rochester.edu/highland/departments-centers/bariatrics/right-foryou/morbid-obesity.aspx>.