Laparoscopic Roux-En-Y Gastric Bypass for Morbid Obesity

Introduction and Case Report

Introduction

Bariatric surgery procedures have increased dramatically in the last decade, mainly due to the growing epidemic problem of morbid obesity in the United States and the advent and acceptance of minimally invasive techniques to perform bariatric operations. The Roux-en-Y gastric bypass procedure, in which a very small gastric pouch is created and a Roux limb of jejunum is anastomosed, was the most common procedure performed in 2005.

Case Report

The patient is a 42-year-old woman, height: 5′6″; weight: 240 lb; with a body mass index (BMI) of 39, who had started gaining weight when she was 18 years of age. She has failed several diet treatments for losing weight. She has type 2 diabetes, hypertension, obstructive sleep apnea, and gastroesophageal reflux disease (GERD).

1. Which of the following conditions improve with weight loss after a laparoscopic Roux-en-Y gastric bypass?

   1. Type 2 diabetes only
   2. Hypertension only
   3. Obstructive sleep apnea only
   4. Degenerative arthritis only
   5. All of the above conditions improve with weight loss

Readers are encouraged to respond to George Lundberg, MD, Editor of MedGenMed, for the editor's eye only or for possible publication via email: glundberg@medscape.net

Gastric Bypass Procedure – Associated Benefits

Patients who lose weight after undergoing a gastric bypass procedure note improvement in pain in all weight-bearing joints. The gastric bypass procedure is associated with dramatic improvement in hyperglycemia, hyperinsulinemia, insulin resistance, and response to intravenous glucose tolerance tests, and results in a decreased need for medication for related conditions. Systolic blood pressure has been shown to decrease more than 25 mm Hg and diastolic pressure to decrease by 5-10 mm Hg in patients who have undergone a gastric bypass procedure; both of these findings are more pronounced in men. Additionally, the improvement in lipid profile seen in gastric bypass patients is greater than would be expected with weight loss alone: Total cholesterol levels are reduced by 25%, high-density lipoprotein levels and subfractions are improved, and low-density lipoprotein and triglyceride levels are all significantly reduced. There is also resolution (50% to 85%) or improvement (10% to 30%) in the degree of hepatic steatosis in patients who have undergone gastric bypass.[3] Gastric bypass patients experience fewer symptoms of GERD, with or without a concomitant antireflux procedure. Weight loss following a gastric bypass procedure is also associated with decreased cerebrospinal fluid pressures (from 320 mm H₂O to < 175 mm H₂O), with resolution of headaches and pulsatile tinnitus. Gastric bypass patients have significant improvement in symptoms related to sleep apnea, apnea index, and time in deeper sleep stages. Lung volumes, arterial blood gases, respiratory muscle strength, and endurance all improve following gastric bypass procedure. There is also improvement in venous stasis.[3]

• 2.
  Which of the following patients has a clear indication for undergoing surgical treatment for morbid obesity?

  1. A 16-year-old adolescent boy, BMI = 38
  2. A 34-year-old woman with type 2 diabetes, hypertension, obstructive sleep apnea, BMI = 38, who has failed several diets
  3. A 68-year-old man with congestive heart failure, 25% ejection fraction, obstructive sleep apnea, type 2 diabetes, and BMI = 36, who is currently trying to quit alcohol use
  4. A 22-year-old woman, BMI = 35, who is not interested in diets or exercise

Guidelines for Bariatric Surgery

The guidelines adopted by the American Society for Bariatric Surgery and the Society of American Gastrointestinal Endoscopic Surgeons in June 2000, established that surgical therapy should be considered for individuals who have a BMI > 35-40 kg/m² and who also have obesity-related comorbidities, or who have a BMI > 40 kg/m² even without comorbidities if the weight adversely affects their life, and for whom dietary attempts at weight control have been ineffective.[1,4]

The 1991 National Institutes of Health Consensus Development Conference statement on gastrointestinal surgery for severe obesity in 1991 established a set of parameters, and as a result, the following guidelines have been universally adopted by surgeons and insurance companies when determining a patient's candidacy for bariatric surgery:[4,5]

• An operation should be offered to those patients with good information and motivation, without excessive operative risk, and who are able to comply with the postoperative regimen and long-term follow-up.

• Patients with a BMI exceeding 40 kg/m² could be considered for an operation if they strongly desire a substantial weight loss and the weight impairs the quality of their lives.

• In certain circumstances, less severely obese patients (BMI, 35-40 kg/m²) may be suitable for an operation if they present high-risk comorbid conditions, such as severe diabetes mellitus, severe sleep apnea, or Pickwickian syndrome, or have physical problems interfering with employment, family function, ambulation, etc.

• Nonsurgical therapy should be offered for those patients with a desire to lose weight and who are consulting for the first time, and should include plans for diet and exercise along with behavior support and modification.

• Patients who are candidates for surgical procedures should be selected carefully after evaluation by a multidisciplinary team involving medical, surgical, psychiatric, and nutritional experts.

• The operation should be performed by a surgeon with substantial experience in the appropriate procedures and in a clinical setting with adequate support for all aspects of the operative management and assessment.

• There should be postoperative care, nutritional support, and strict surveillance and monitoring after the operation.

The main contraindications for laparoscopic bariatric surgery include the following:[1]

• Patients with inadequate cardiopulmonary reserve to tolerate the procedure, or end-stage cardiac or lung disease;[2] noncontrolled drug or alcohol dependency; or impaired intellectual capacity

• Patients with large incisional hernias requiring repair at the time of the bariatric procedure;

• Presence of intra-abdominal adhesions preventing an adequate visualization and dissection;

• Abdominal compartment syndrome or inability to achieve pneumoperitoneum; and

• Prader-Willi syndrome, because surgical therapy does not alter the constant desire to eat.[2]

Additionally, the role of bariatric surgery in patients younger than age 18 and older than 65 is not well defined. Cultural differences are also currently being studied.

• 3.
  Which of the following is the most common complication after a laparoscopic Roux- en-Y gastric bypass operation?

  1. Anastomotic stenosis
  2. Hernia
  3. Thromboembolic events
  4. Leaks

Complications of Gastric Bypass Surgery

Anastomotic stenosis at the gastrojejunostomy site is the most common complication of gastric bypass surgery, and has been reported to occur at a rate ranging from 2% to 14% in various series,[2] but the majority of studies report between 2% and 5.2%.[1,2] It usually presents as progressive intolerance to solids then liquids, in a setting where they were tolerated previously. This complication is quite successfully managed with endoscopic or fluoroscopic balloon dilation. Unless a marginal ulcer is associated with the stenosis, reoperation is usually not required.[6]

Proximal anastomotic leaks or staple-line disruptions are tolerated poorly by the bariatric patient. Leaks are often subtle in their initial presentation; the only indication may be sustained tachycardia (> 120 beats per minute). Typical symptoms, such as abdominal pain, fever, or leukocytosis, can be indistinguishable from cardiac events, pulmonary embolism, acute gastric distention, or hemorrhagic shock. Work-up and evaluation must be expeditious and directed by clinical suspicion. If a leak is suspected, diagnostic laparoscopy is the most definitive method to rule out this entity. Operative endoscopy will be helpful during surgery. There should be an attempt to identify and repair the defect, recognizing that this will often fail. Drainage is essential, and enteric access via a gastrostomy tube in the gastric remnant can be established at this time, preventing gastric distention. Later, this tube can be used as a conduit for nutritional support if an enterocutaneous fistula develops. Other complications of bariatric surgery include internal hernias (incidence approximately 1.5% in various studies,[7] with a higher incidence of 4.6% reported by Higa;[1]) gallstone formation; bleeding; marginal ulcers; thromboembolic events, with an incidence of 0.2% to 1.2%;[1,2,7–10] infections; and death.[1–3,6,8–11]

• 4.
  A patient who underwent a laparoscopic gastric bypass procedure presented to the emergency department 8 weeks after surgery with abdominal pain, nausea, and retching. The most likely diagnoses include all of the following EXCEPT:

  1. Stricture
  2. Marginal ulcer
  3. Internal hernia with small bowel obstruction (SBO)
  4. Gastro-gastric fistula

Postoperative Complications and Causes of Reoperation – Further Discussion

Patients who have undergone a Roux-en-Y gastric bypass procedure and present with a clinical or radiologic picture of SBO require reoperation. The potential for internal hernias after this operation makes strangulation a frequent type of bowel obstruction. Patients who present with bowel obstruction rather than ileus in the immediate postoperative period must be promptly reexplored; retrograde distention of the biliopancreatic limb and distal stomach can result in rupture of the distal gastric staple line with subsequent peritonitis.[6]

A marginal ulcer occurs in 2% to 10% of patients;[2,5] this incidence can be decreased by preoperative treatment of those patients who have been identified with Helicobacter pylori colonization of the stomach. However, it is likely that the cause of stomal ulcer is multifactorial and may result from a combination of acid from parietal cells in the pouch, ischemia of (or tension on) the Roux-en-Y limb to the pouch, and a history of tobacco or nonsteroidal anti-inflammatory drug (NSAID) use. Patients most often present with stomal ulcer in the first 3 months after gastric bypass. Typically, the ulcer is on the jejunal side of a gastrojejunostomy. Bleeding can be severe, necessitating transfusions or emergent exploration. If the pouch was made too large, it may contain a substantial amount of parietal cell mass resulting in significant acidity in the otherwise acid-free pouch environment. Staple-line dehiscence results in acid traversing the incomplete staple line into the proximal gastric pouch, potentially causing marginal ulcers. Symptoms include severe dyspepsia, burning retrosternal pain, and vomiting. Diagnosis is made via endoscopy. It is important to rule out H pylori infection as an etiologic factor. Treatment involves proton-pump inhibitors (PPIs) and sucralfate, with the addition of antibiotics if the patient is H pylori-positive. Occasionally these ulcers become refractory to treatment. In these settings, other causes of peptic ulcer disease, such as gastrinoma, should be investigated. Generally, if the ulcer is refractory to PPIs, then overproduction of acid may not be the problem and ischemia of the end of the Roux-en-Y limb may be the cause. When medical treatment fails, surgery is required, with resection of the ulcer and revision of the pouch or staple line if they prove to be the underlying cause of the ulcer. Prolonged and protracted stomal ulcer may eventually lead to stomal stenosis because of cicatrization.[2,7,10]

The more common reasons for severe food intolerance are anastomotic strictures and internal hernias. Strictures occur at the gastrojejunostomy approximately 5% to 15% of the time after Roux-en-Y gastric bypass. Strictures can usually be easily managed with endoscopic dilation.

There are several internal hernias created by division of bowel mesentery; they can occur at the jejunojejunostomy, between the roux limb mesentery and the transverse colon mesentery (Peterson's defect), and at the transverse colon mesentery. An internal hernia is created if the surgeon elects to bring the roux limb in a retrocolic position. These hernias can result in a small bowel obstruction, although this obstruction can be intermittent and can, therefore, be difficult to diagnose.

Gastro-gastric fistulas occur more frequently with procedures in which the stomach is not divided, such as vertical banding gastroplasty, but have also been infrequently reported in divided gastric bypass. The reported incidence ranges between 2% and 10% in different series, although many cases may be subclinical. These fistulas are likely the result of breakdown of the mucosa resulting from migrating staples and other foreign material. Lack of integrity of the gastric lining facilitates the action of the gastric digestive process. A staple-line disruption typically leads to the fistula, and failure of weight loss or a weight regain due to increased food consumption may result. Surgical revision may be indicated if there is significant weight regain or if an intractable stomal ulcer and pain develop. Interposition of the jejunal limb between the pouch and the excluded stomach may reduce the incidence of this complication. An intact serosa appears to block the digestion of bowel wall by gastric enzymes. Correction involves restapling and dividing the stomach.[6,7,10,12,13]

Surgical Procedure

Description of the Procedure

The patient is placed on a dedicated bariatric table that will support being positioned at a 45° angle, with the head up. We use 5 ports, each between 5 and 12 mm. The operation begins by making a small (approximately 20-30 cc) gastric pouch from the proximal portion of the stomach. The blood supply from the left gastric artery is kept intact. Before completing the pouch, 1 part of a circular 25-mm stapling device (EEA [end-to-end anastomosis]; Autosuture; Norwalk, Connecticut) is placed in the pouch.

The next step is to create a Roux-en-Y limb. We identify the ligament of Treitz and divide the jejunum 30 cm distal to it. The distal end will be connected to the gastric pouch. We then measure this limb (Roux limb) between 90 and 120 cm, and connect the proximal jejunum (biliopancreatic limb). This anastomosis (jejunojejunostomy) is performed using a linear stapler and the common channel created by this is closed transversely with a stapler. We then close the mesenteric defect with a running stitch.

The Roux-en-Y limb is passed retrocolic, and using an end-to-end anastomosis stapler we create the gastrojejunal anastomosis. An opening in the transverse colon mesentery is created for passing the Roux limb of the jejunum, and once recovered, we cut the upper two thirds of the end and place an end-to-end anastomosis stapler that we bring inside the abdominal cavity through the left upper quadrant port previously dilated, and create the gastro-Roux-en-Y jejunal anastomosis. Then we close the jejunal end with a stapler.

Upper endoscopy is performed and we insufflate air to test the anastomosis. The Roux-en-Y jejunal limb is secured to the transverse mesocolon with stitches to avoid an obstruction from this internal hernia formation. At the same time we close the Peterson's space (this is the space behind the Roux-en-Y limb). The fascia of all incisions, except the 5 mm, are closed, and then the wounds are irrigated and closed.

Only patients with significant comorbidities or those with sleep apnea requiring use of a BiPAP machine are transferred to the intensive care unit for close monitoring. The postoperative orders include patient-controlled analgesia, later transitioned to oral narcotics, thromboembolism prophylaxis, and antiemetics. Preoperative oral medications are started as soon as clear liquids can be tolerated. Routine follow-up is conducted at 2 weeks, 6 weeks, and then every 3 months for the first year, and then conducted yearly, with nutritional assessments.

Conclusion

Obesity is rapidly increasing in this country and represents one of the greatest health concerns today. In its severe form, the only consistently successful treatment for obesity is surgery. Roux-en-Y gastric bypass is the most commonly performed weight loss procedure performed in the United States. Patients lose, on average, one third of their preoperative weight. As a result, many/most of the obesity-related comorbidities are improved or cured. Until the root cause of obesity is consistently addressed or effective nonsurgical therapies developed, surgery will remain a common treatment for patients with severe obesity.