Student Author

Matthew Zeller

BACKGROUND INFORMATION: The Roux-en-y is a weight loss procedure performed on patients with morbid obesity. This procedure causes weight loss through both restrictive and malabsorptive methods. The expected weight loss at 1-year post-op is 70-75% of excess body weight.

INDICATIONS: The optimal surgical weight loss procedure depends on individual comorbidities, goals, and preferences. In general, patients who are candidates for weight loss surgery include those with:

• BMI ≥40 OR
• BMI >35 with an underlying health condition related to obesity such as type 2 diabetes, hyperlipidemia, obstructive sleep apnea, among others.
  

These guidelines originated from the NIH Consensus Conference Guidelines in 1991 for the treatment of morbid obesity and were updated in 2004 by the American Society for Bariatric Surgery (Buchwald, 2004).

The updates suggested:

• Patients should have attempted self-directed management of their obesity by non-operative means before surgical consideration.
• Patients with a BMI of 30-34.9 with uncontrolled type 2 diabetes or metabolic syndrome are candidates.
• Bariatric patients are best cared for by a multidisciplinary team.

PROCEDURE DESCRIPTION: The Roux-en-y procedure decreases the stomach size (restrictive) and bypasses the duodenum and part of the jejunum (malabsorptive) to promote weight loss.

The stomach is divided to create a small gastric pouch. The jejunum is then separated 50cm distally from its attachment to the duodenum, creating the biliopancreatic (BP) limb. The distal end of the jejunum (roux limb) is then mobilized and brought up to the gastric pouch to create the jejunogastric (JG) anastomosis.

The roux limb may be brought anterior (antecolic) or posterior (retrocolic) to the transverse colon depending on surgeon preference. The BP limb is then anastomosed at 75-150 cm from the JG anastomosis forming the jejuno-jejunal (J-J) anastomosis.

KEY ANATOMY:

• Foregut
• Esophagus
• Gastroesophageal Junction
• Stomach
• Cardia
• Fundus
• Body
• Antrum
• Pylorus
• Gastric Fat Pad
• Angle of His
• Duodenum
• Jejunum
• Ligament of Treitz
• Mesentery of The Small Intestine
• Hindgut
• Transverse Colon
• Taenia Coli

• Greater Omentum
• Lesser Sac
  

NEWLY CREATED ANATOMY:

• Biliopancreatic Limb (Duodenum and 50 cm of the Jejunum)
• Roux Limb (75-150cm of Distal Jejunum)
• Gastric Pouch

RISKS:

• General Surgical Risks

• (Bleeding, Infection, Risk Of Roux-en-y Gastric Bypass)

• Anastomotic Leak (1.0%) (Smith, et al. 2015)

• More Common at the Jejunogastric (JG) Anastomosis

• Bowel Obstruction and Internal Hernia (4.7%) (Angrisani, et al. 2013)
• Bowel Obstruction Commonly from Anastomotic Stenosis
• Marginal Ulcer (<1%) (Abellán, et al. 2015)
• Cholelithiasis (36% at 6 months post-op) (Shiffman, et al. 1991)
• Dumping Syndrome (9.4%) (Nielsen, et al. 2016)
  

KEY LITERATURE:

• STAMPEDE Trial (Schauer, et al. 2012)

Randomized controlled trial comparing medical therapy and weight loss surgery vs. medical therapy alone in the treatment of uncontrolled diabetes in obese patients.

Findings showed a significant difference in A1c levels in the medical and surgical treatment group when compared to the medical treatment only at 1 and 3 years follow-up.

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To watch the surgery live, click here: https://watch.giblib.com/video/7836