In recent years, better clinical understanding of procedures combining restrictive and malabsorptive approaches has increased the choices of effective weight loss surgery for thousands of patients. By adding malabsorption, food is delayed in mixing with bile and pancreatic juices that aid in the absorption of nutrients. The result is an early sense of fullness, combined with a sense of satisfaction that reduces the desire to eat.
According to the American Society for Bariatric Surgery and the National Institutes of Health, Roux-en-Y gastric bypass is the current gold standard procedure for weight loss surgery. It is one of the most frequently performed weight loss procedures in the United States. In this procedure, stapling creates a small (15 to 20cc) stomach pouch. The remainder of the stomach is not removed, but is completely stapled shut and divided from the stomach pouch. The outlet from this newly formed pouch empties directly into the lower portion of the jejunum, thus bypassing calorie absorption. This is done by dividing the small intestine just beyond the duodenum for the purpose of bringing it up and constructing a connection with the newly formed stomach pouch. The other end is connected into the side of the Roux limb of the intestine creating the "Y" shape that gives the technique its name. The length of either segment of the intestine can be increased to produce lower or higher levels of malabsorption.
- The average excess weight loss after the Roux-en-Y procedure is generally higher in a compliant patient than with purely restrictive procedures.
- One year after surgery, weight loss can average 77% of excess body weight.
- Studies show that after 10 to 14 years, 50-60% of excess body weight loss has been maintained by some patients.
- A 2000 study of 500 patients showed that 96% of certain associated health conditions studied (back pain, sleep apnea, high blood pressure, diabetes and depression) were improved or resolved.
- Because the duodenum is bypassed, poor absorption of iron and calcium can result in the lowering of total body iron and a predisposition to iron deficiency anemia. This is a particular concern for patients who experience chronic blood loss during excessive menstrual flow or bleeding hemorrhoids. Women, already at risk for osteoporosis that can occur after menopause, should be aware of the potential for heightened bone calcium loss.
- Bypassing the duodenum has caused metabolic bone disease in some patients, resulting in bone pain, loss of height, humped back and fractures of the ribs and hip bones. All of the deficiencies mentioned above, however, can be managed through proper diet and vitamin supplements.
- A chronic anemia due to Vitamin B12 deficiency may occur. The problem can usually be managed with Vitamin B12 pills or injections.
- A condition known as "dumping syndrome " can occur as the result of rapid emptying of stomach contents into the small intestine. This is sometimes triggered when too much sugar or large amounts of food are consumed. While generally not considered to be a serious risk to your health, the results can be extremely unpleasant and can include nausea, weakness, sweating, faintness and, on occasion, diarrhea after eating. Some patients are unable to eat any form of sweets after surgery.
- In some cases, the effectiveness of the procedure may be reduced if the stomach pouch is stretched and/or if it is initially left larger than 15-30cc.
- The bypassed portion of the stomach, duodenum and segments of the small intestine cannot be easily visualized using X-ray or endoscopy if problems such as ulcers, bleeding or malignancy should occur.
For the last decade, laparoscopic procedures have been used in a variety of general surgeries. Many people mistakenly believe that these techniques are still "experimental." In fact, laparoscopy has become the predominant technique in some areas of surgery and has been used for weight loss surgery for several years. Although few bariatric surgeons perform laparoscopic weight loss surgeries, more are offering patients this less invasive surgical option whenever possible.
When a laparoscopic operation is performed, a small video camera is inserted into the abdomen. The surgeon views the procedure on a separate video monitor. Most laparoscopic surgeons believe this gives them better visualization and access to key anatomical structures.
The camera and surgical instruments are inserted through small incisions made in the abdominal wall. This approach is considered less invasive because it replaces the need for one long incision to open the abdomen. A recent study shows that patients having had laparoscopic weight loss surgery experience less pain after surgery resulting in easier breathing and lung function and higher overall oxygen levels. Other realized benefits with laparoscopy have been fewer wound complications such as infection or hernia, and patients returning more quickly to pre-surgical levels of activity.
Laparoscopic procedures for weight loss surgery employ the same principles as their "open" counterparts and produce similar excess weight loss. Not all patients are candidates for this approach, just as all bariatric surgeons are not trained in the advanced techniques required to perform this less invasive method. The American Society for Bariatric Surgery recommends that laparoscopic weight loss surgery should only be performed by surgeons who are experienced in both laparoscopic and open bariatric procedures.
Frequently Asked Questions
Q: Does your diet have to change after Roux-en-Y gastric bypass surgery?
A: Yes. Every patient meets with the dietitian before, during and after surgery so you learn our dietary guidelines. The dietitian will help you learn ways to change your eating behaviors so you lose weight and stay healthy. Right after patients undergo surgery, they will follow a special diet PhaseI through 4 starting with clear liquids. It may take about 1 to 3 months for patients to move from clear liquids to regular foods. It may be best to eliminate sweets and fatty foods to avoid digestive problems.
Q: How long will it take me to recover from Roux-en-Y gastric bypass surgery?
A: Recovery periods and healing may vary from person to person and may depend on your overall (pre-surgery) health, weight and type of surgery. Generally it takes 1 to 3 weeks to recover from laparoscopic gastric bypass and 2 to 6 weeks to recover from open gastric bypass surgery. Your surgeon will advise you when it is best to return to work or full activity.
Q: Do special foods need to be purchased after Roux-en-Y gastric bypass surgery?
A: Yes, at first you may need to have a protein supplement to help with recovery and healing. Adequate protein (60 to 70 grams per day for women and 70 to 80 grams per day for men) helps maintain lean body mass during quick weight loss and helps prevent hair loss. Protein powders may be purchased at your local supermarket, drug store, health food store, or on-line. The dietitians can provide suggestions.
Q: Will I need to take vitamins every day after Roux-en-Y gastric bypass surgery?
A: Yes a multi-vitamin (adult dose), B12 (500 mcg a day) and calcium citrate (500 mg twice a day) are recommended to avoid vitamin and mineral deficiencies. Lab work will be done on a regular basis to check your levels of protein, iron, calcium, electrolytes and B12 to make sure you are getting enough vitamins.
Q: When can I drink carbonated beverages?
A: It is recommended that carbonated beverages be totally avoided, as the carbonation fills and possibly stretches the new pouch.
Q: What is the “dumping syndrome”?
A: This can occur when you eat high sugar or high fat foods or beverages. The symptoms may be cramps, nausea, sweats, chest pain, light headedness, vomiting and a sudden urge to move your bowels (diarrhea). This often lasts up to 45 minutes and can be avoided by eliminating some foods especially high sugar liquids.
Q: Why am I vomiting after gastric bypass surgery?
A: This can happen after surgery for many reasons: often it is related to what or how you are eating. Vomiting may be caused by: advancing your diet too soon (Phase 1 to Phase 2 for example), eating too fast, not chewing enough, eating too much, eating food that is too dry, too sugary, or too high in fat. Remember to take care of your new stomach by starting new ways of eating! Take smaller portions, chew slowly and thoroughly, and do not drink liquids with meals. Your dietitian can help you plan menus that are nutritious and include foods you like.
Q: Can I drink alcohol after gastric bypass?
A: It is best to wait at least 6 months after RYGB before having any kind of alcoholic beverage. But remember that alcohol should be avoided as it is high in calories and has no nutritional value. If you choose to drink alcohol, consider that it will be absorbed more quickly so be responsible with driving.
Q: Can I ever lose too much weight?
A: It is unlikely, but you must follow the dietary guidelines to insure good nutritional health.
Q: Can I re-gain weight?
A: Yes, if you return to the same unhealthy eating habits, or snack too often or eat high calorie foods, or drink high calorie beverages often. The RYGB is a tool to help you change your eating style and begin new, better habits like regular exercise.
Q: Is hair loss normal?
A: Yes, often people will loose hair between the 4th and 6th post-operative month. The hair loss may seem excessive but generally it grows back. Eating adequate protein will help maintain hair. Significant hair loss is rare.
Q: What types of pain medications should I avoid?
A: You must NOT take any non-steroidal anti-inflammatory (NSAID) medications like aspirin, ibuprofen (Advil or Motrin). If you are not sure if a medication is a NSAID—call your pharmacist and ask. For pain we recommend Tylenol (acetaminophen), or for arthritis pain drugs classified as COX-2 inhibitors (like Celebrex) but always check with your PCP, pharmacist, surgeon, dietitian or nurse before taking any type of pain medicine.
Q: What about getting pregnant after RYGB surgery?
A: We recommend avoiding pregnancy during the first year after surgery due to increased risk to you and the baby. Birth control pills, patches or injections may not work as well due to the rapid weight loss so choose a barrier to contraception (like condoms).
Q: Do I need a psychological evaluation before surgery?
A: Yes, all patients must talk with a qualified mental health professional before having RYGB surgery. This will help determine your readiness for gastric bypass, the life changes that go with it and the life-long follow-up required. A qualified mental health professional can make recommendations about psychological and behavioral problems that should be resolved before surgery to help insure success. Some people decide to continue seeing the psychologist after RYGB to help them deal with stress and changes in relationships and body image.
Q: Will my skin sag after losing a lot of weight?
A: Because there is a large amount of fat between the skin and the “true body”, the skin may sag as that fat is lost. During the first six months, with rapid weight loss, the skin cannot adjust and may sag. Over time the elasticity of the skin may improve and some shrinking of the skin can occur. Many things affect this including age, weight before surgery and activity level.
: What can be done about the excess skin on the stomach and other areas?
A: The skin of the lower abdomen is called the pannus and may be surgically removed by a qualified plastic surgeon. This operation (called panniculectomy) may or may not be covered by insurance. It is important to document with your family doctor, any skin irritations that develop or have occurred over time. Photos of problem areas may also be helpful in getting this type of surgery approved. It is best to wait until you have reached your goal weight or until your weight loss has slowed down before you consider plastic surgery. This type of surgery may involve a 1 to 3 day hospital stay and large incisions.
Q: Will my new small stomach-pouch stretch or get larger?
A: Over time, if you repeatedly overeat or “binge” eat (that means eat to the point of discomfort) it can ruin the new stomach-pouch by making it larger.
Q: If my pouch stretches, can it be fixed?
A: It could be made smaller with a re-operation but that may be high risk due to scar tissue from the first surgery.
Q: Will I be hungry after surgery?
A: People of normal weight usually get the “full” sensation after eating the “right” amount; their appetite center works correctly. Often this is not the case with someone who is morbidly obese. A morbidly obese person may not know when they are full or when they are (really) hungry. This impaired satiety causes overeating. But, how you experience getting “full” after Roux-en-Y gastric bypass should change. Before surgery, you may not have been able to recognize when you had eaten the appropriate amount of food and calories, after surgery you should be “full” with smaller amounts of food. Your feeling of hunger should become more specific and so you will re-learn to eat good foods, when you are hungry and stop when you are “full”.
After RYGB surgery you will not feel hungry because your satiety (or “fullness”) will come from stretching the walls of your new small stomach-pouch. The right amount of food will cause the pouch to stretch and you will feel full. It is very important NOT to take liquids with meals, this will stretch the pouch too much and the feeling of fullness will not last until the next meal. To
You must carefully consider what food and liquid to consume. Remember that the volume of food will stretch the pouch and make you feel full. For example, a large bowl of salad will make you feel full, a cube of butter or cheese or other high calorie food may not.