Roux-en-Y gastric bypass for morbid obesity - Home Study Program

AORN Journal,  Oct, 2002  by Cynthia J. Barrow

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SURGICAL OPTIONS

The concept of gastric surgery to control obesity grew from results of surgical procedures for cancer or severe ulcers in which large portions of the stomach or small intestine were removed. Patients undergoing these procedures lost weight postoperatively. This observation led surgeons to perform these procedures electively for the purpose of weight reduction. (38) The first bariatric procedure (ie, intestinal bypass) induced weight loss by causing malabsorption (ie, food is poorly digested and absorbed). The problem with this procedure was that it caused a loss of essential nutrients, and its side effects were unpredictable and sometimes fatal. (39) This original form of bypass is no longer used, but the concept has been modified into the NIH-sanctioned procedures performed today.

Surgical procedures promote weight loss in two ways--restriction (ie, limiting the amount of food intake) and malabsorption. Purely restrictive procedures include gastric banding and vertical-banded gastroplasty. Restrictive procedures promote weight loss by restricting intake via a small stomach capacity and delayed emptying, which causes a sense of fullness. (40) Restrictive surgical procedures lead to weight loss in almost all patients; however, patients may develop the ability to "out eat" the restriction, thus causing weight regain in some patients. (41)

Current malabsorptive procedures combine the assets of restrictive surgery with the additional benefit of reduced calorie and nutrient absorption. The result is greater weight loss, usually up to two-thirds of excess weight is lost within two years. Current malabsorptive procedures include Roux-en-Y gastric bypass and biliopancreatic diversion (eg, the Scopinaro procedure). Biliopancreatic diversion is not used widely because of the high risk of nutritional deficiencies, leaving Roux-en-Y gastric bypass as the current procedure of choice for patients requiring surgery for morbid obesity. (42)

Roux-en-Y gastric bypass is accomplished by creating a small (ie, approximately 30 mL) gastric pouch by placing staples across the stomach. The jejunum is divided, the distal limb is brought up, and a gastrojejunostomy is performed with the gastric pouch. The proximal limb of the jejunum is anastomosed to the distal jejunum at a predetermined distance from the gastrojejunostomy (Figure 1). (43) The predetermined distance varies by surgeon and facility. At Doylestown Hospital, Doylestown, Pa, the jejunojejunostomy is created 100 cm from the gastrojejunostomy in patients with a BMI less than 50, or 150 cm in patients with a BMI greater than 50.

[FIGURE 1 OMITTED]

Roux-en-Y gastric bypass has demonstrated the best ratio of results to complications among bariatric procedures, giving it status as the "gold standard" in bariatric surgery. (44) The benefits include

* better long-term weight loss,

* fewer complications and less need for revisions,

* better lifestyle with less vomiting, and

* good reflux control because the majority of the parietal cell mass and bile are barricaded from the esophagus. (45)