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Roux–en–Y

Section: UGI Sub-section: Bariatrics Curriculum: Curriculum, page 83

  • Roux-en-Y gastrojejunostomy anastomoses the remnant stomach to an isoperistaltic roux limb of jejunum
  • The proximal jejunum (BP limb) is anastomosed to the distal Roux limb in an end-to-side fashion.
  • Does not preserve duodenal or jejunal continuity

Roux–en–Y Gastric bypass

Principles

  • Both malabsorptive & restrictive procedure
  • Prophylactic Cholecystectomy recommended if gallstones
    • ERCP post-op is impossible in these patients; gallstone risk is high
  • Roux-limb should be at least 75cm-150cm in length (length debated)
  • BP limb should be at least 50cm from DJ flexure (between 50-100cm)
  • After Gastric Bypass
    • All patients started on
      • Multivitamins
      • B12 / Folate / Iron regularly tested and supplemented as required

Mechanism of Weight Loss

  • Primarily restrictive due to small pouch
  • Malabsorptive component adds to weight loss
  • Gastrojejunostomy anatomy
    • Leads to dumping physiology
    • Has negative conditioning response against high-sugar diet
  • Roux-limb (Alimentary) length
    • Optimal length disputed
    • Balance between weight reduction and malabsorption
    • Increased length = Malabsorption due to decreasing length of common channel
    • Should not be > 150cm
  • Ghrelin
    • Normal pulsatile release inhibited in RYGB due to the foregut bypass configuration
      • Also seen in Sleeve Gastrectomy
    • May contribute to appetite suppression
    • NB: Over time Ghrelin levels may increase back to normal
  • Other Hormones
    • GLP-1 and CCK may also promote anorectic state

Procedure

  • Trochar placement
  • Creation of small lesser curve gastric pouch
    • Blunt dissection 4-6cm from GOJ to enter lesser sac
    • 45mm stapler fired obliquely
    • Blunt dissect the retrogastric attachments aiming to the angle of His
    • Pass Bugie
    • 2-3x 60cm stapler firing towards Angle of His to complete 20cc pouch
  • Measure BP limb
    • Lift transverse colon up to identify DJ flexure
    • Measure 50cm
    • Fire 60cm stapler
    • Take a small amount of mesentery in-between
    • Mark BP limb - stitch or clip or burn
  • Measure Roux limb
    • Measure 90-150cm
  • Create jejunpjejunostomy
    • Create a stapled or hand sewn JJ
    • Place anti-obstruction stitch
    • Close mesenteric defect by continuing running this stitch down
  • Create gastrojejunostomy
    • Pass the Roux limb retro- or anti-colic
    • Create the GJ - stapled or hand-sewen
    • Trim Candy Cane limb if required
  • Close mesenteric defects

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Pros and Cons

  • Pros
    • Effective for weight loss and comorbidities
    • 50-60% EWL at 3 yrs
    • T2DM in remission in 70%
    • HTN resolved in 70%
    • OSA resolved in 80%
    • Improves GORD in 90% of cases (only bariatric surgery proven to do so)
    • Improves gut hormone profile to reduce appetite
      • PYY + GLP-1 induced satiety
    • Less risk of malabsorption that BPD/DS
    • But more than Gastric Sleeve or Band
    • Partially reversible
  • Cons:
    • Steep learning curve
    • Difficult to perform ERCP post-op
    • Generally only recommended in high-volume centres
    • Reasonable cost
    • Longer operative time and longer inpatient admission
    • Moderate complication rate
      • 10% Morbidity rate
      • 0.3 - 1% Mortality

Complications

  • Early
    • Leak 3% (usually at gastrojejunostomy or above)
    • Staple line bleed 3%
    • Stricture
    • Roux-en-O configuration (requires re-do surgery)
  • Late

Laparoscopic vs Open RYGB

  • Laparoscopic patients
    • Less likely to have re-operations
    • Less likely to have post-op complications, incl. leak
    • Have shorter length of stay
  • Lap Bypass vs Lap Band for obesity
    • Small increase in early complications in bypass group
    • More (delayed) complications in lap band group
    • Less weight loss with lap band
      • 50% vs 70% of EWL at 2-10yrs
  • Modern Sleeve vs Modern RYGB
    • Essentially equal in outcomes for co-morbidities except for REFLUX
    • Sleeve also has poor outcomes for dyslipidaemia

Fobi Pouch Principles

  • < 30mL vertical pouch (usually 5-10mL)
  • Vertical orientation – less liable to distension
  • Divided stomach
  • Reinforced staple line by patching Roux limb along staple line
  • 1-2cm outlet/anastomosis
  • 6.5cm Silastic ring
    • Prevents outlet widening with time
    • Ring requires removal in 2%

Graph View

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