Gastric Bypass Surgery
Gastric Bypass (Roux-en-Y) has long been known as “the Gold Standard” in weight loss surgery. It has earned this description because of its longevity. This procedure has been performed since the 1970s in various forms and follow up has demonstrated it to be safe and effective with limited side effects. Because the experience is so vast, the post-operative problems and pitfalls which might occur are generally well known and can be anticipated and treated PRIOR to becoming major problems. It is known by many slang names including “the Bypass”, “stomach stapling,” and “the Roux procedure”. The technique has varied over time, but the overall reconstruction has been generally consistent.
Gastric Bypass Surgery includes identifying the small intestine at a reproducible landmark called “the Ligament of Treitz”, measuring a distance downstream and then separating the small intestine. This portion is then placed to the side. The downstream half is then measured a distance of 75-150 centimeters from the cut point. At this point, the front section, which had been put to the side, is then reattached to the downstream intestine. The upper end of the remaining front piece of the reconstructed intestine is then marked so it can be found later and attached to the new stomach pouch.
The stomach pouch is created by cutting the stomach around a balloon sizer which is 30cc in size (approximately a large chicken egg). The stomach pouch is completely separated from the lower aspect of the stomach. This seals it off from receiving food, but it will still remain in the body. The marked front end of the reconstructed intestine is then identified and brought up to the stomach pouch where it is attached, completing the bypass procedure.
There are many variations in this procedure which can affect its function. Some bariatric surgeons make the stomach pouch larger than others. Some attach the small intestine with suture, some with circular staplers, and some with linear staplers. Sometimes the intestine is routed in front of the lower stomach remnant (ante gastric), sometimes behind (retro gastric). Some will pass the intestine over the colon prior to making the stomach attachment (ante colic). Some surgeons will pass it behind the colon through the fatty tissue known as mesentery (retro colic). The reasons for the variations include surgeon preference and sometimes patient anatomy. In the past, when gastric bypass surgery was performed in open surgery, the gastric pouch was stapled, but not separated from the remainder of the stomach. Each of these variations works well, but each can have its own complicating factors. It is always a good idea as a patient to have an idea of exactly what type of reconstruction has been performed.
NJ Bariatric Institute surgeons favor ante colic, ante gastric reconstruction with a circular stapled attachment. This technique provides the best reproducibility of outcomes by standardizing the size of the gastric pouch, the size of the attachment between the gastric pouch and the small intestine, the length of the intestine bypassed and the position of the pieces inside the abdomen. The “anterior approach” allows the defects between the attached pieces to be sutured closed in order to reduce the possibility of hernias or complications later in life. In the case that there is ever a surgical complication, the organs are readily accessible leading to a minimum of disruption if something requires repair.
Most bariatric surgeons currently favor this approach.