surgical treatment for morbid obesity: the laparoscopic...

Surgical Treatmentfor Morbid Obesity:The LaparoscopicRoux-en-Y GastricBypass

Myron S. Powell, MD, Adolfo Z. Fernandez Jr, MD*

KEYWORDS

� Obesity � Gastric bypass � Roux-en-Y � Laparoscopy

Obesity, defined as a body mass index (BMI) of 30 (ie, body weight of 30 kg divided byheight in meters squared [30 kg/m2]) or greater, is the excess accumulation of body fatthat adversely effects health and decreases life expectancy.1,2 A body weight thatexceeds the ideal body weight by more than 100 lb (45.4 kg) or a BMI greater than35 has been termed morbid obesity. Historically obesity was widely perceived asa symbol of wealth and fertility, and still is in some parts of the world.2 Viewed asone of the most serious public health problems of the twenty-first century, it is nowthe leading cause of preventable death in the United States, with increasing preva-lence both in adults and children.3

During the past 20 years there has been a dramatic increase in obesity in the UnitedStates. In 2009, only Colorado and the District of Columbia had a prevalence ofobesity less than 20%.4 Thirty-three states had a prevalence equal to or greaterthan 25%; 9 of these states (Alabama, Arkansas, Kentucky, Louisiana, Mississippi,Missouri, Oklahoma, Tennessee, and West Virginia) had a prevalence of obesity equalto or greater than 30%.4 Medical weight reduction programs have not been able toyield substantial long-lasting success in comparison with surgical intervention.5

BRIEF HISTORY OF THE EVOLUTION OF THE LAPAROSCOPIC ROUX-EN-Y GASTRICBYPASS PROCEDURE

The history of surgery for obesity dates back to the 1950s but because of the growingobesity epidemic, the most rapid advances have occurred in the last several decades.

Department of General Surgery, Wake Forest University School Of Medicine, Winston-Salem,NC 27157, USA* Corresponding author.E-mail address: [email protected]

Surg Clin N Am 91 (2011) 1203–1224doi:10.1016/j.suc.2011.08.013 surgical.theclinics.com0039-6109/11/$ – see front matter � 2011 Published by Elsevier Inc.

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Powell & Fernandez1204

A.J. Kremen is credited with the first bariatric operation in the United States, in 1954.He introduced the jejunoileal bypass procedure for weight loss. This procedureinduced a state of malabsorption by bypassing most of the intestines while keepingthe stomach intact, and was successful for weight loss. However, the morbidity ofthe procedure was high, having complications such as severe electrolyte imbalances,dehydration, bypass enteritis from bacterial overgrowth of the bypassed intestine,diarrhea, cirrhosis, interstitial nephritis, and various vitamin and mineral deficiencies.The mortality rate was high, and many patients have required reversal of the proce-dure.6,7 In the 1980s the jejunoileal bypass was abandoned and is no longer a recom-mended bariatric surgical procedure. Many experimental operations were tested onmorbidly obese patients throughout the 1950s and 1960s. Surgery involving thestomach became the more prevalent choice for the surgical treatment of morbidobesity.6,7

The development of the gastric bypass procedure for the treatment of morbidobesity has been credited to Dr Edward E. Mason.8 In 1966 Mason and Ito appliedthe concepts of partial gastrectomy to obese females for weight reduction, becauseof the observation that female patients undergoing partial gastrectomy for ulcerdisease remained underweight and had difficulty gaining weight. Mason and Ito8 intro-duced the first case series of gastric restrictive procedures. The procedure, referred toas gastric bypass, involved horizontally transecting the stomach.8 The pouch wascomposed of cardia and fundus, and was completely divided from the distal part ofthe stomach.8 As with its predecessor, the Billroth II, their procedure incorporateda retrocolic “loop” with a hand-sewn gastrojejunostomy (Fig. 1).9

The gastric outlet was measured and restricted to maximize weight loss. Mason andIto modified the procedure and reported the specifics of the gastrojejunostomy asrelated to weight loss. Further refinements were made, such as calibrating the volumeof the gastric pouch and changing the diameter of the gastrojejunostomy.9 The best

Fig. 1. Mason gastric bypass with loop gastrojejunostomy, 1966.

Surgical Treatment for Morbid Obesity 1205

results were demonstrated with a calibrated 50-mL gastric pouch and a 12-mmstoma.9 After receiving criticism from surgeons worldwide because of an increasedrisk of the development of a marginal ulcer as a consequence of the gastric restrictionand anastomosis, Mason and colleagues10 published a study reporting that the upperpart of the stomach produces relatively little acid and that marginal ulceration wouldbe unlikely. Later, in 1977, Alden11 introduced a modification of the gastric bypassthat did not involve complete transection of the stomach and separation of the gastricpouch from the distal stomach. Instead, surgical staplers were used to create a parti-tion across the upper portion of the stomach to reduce the intake of food and createthe feeling of satiety, with a small amount of food.11 Surgeons continued to modify theinitial attempts of Mason and Ito in gastric restrictive procedures, which ultimatelycontributed to the evolution of the current laparoscopic Roux-en-Y (RNY) gastricbypass procedure.In 1977, Griffen and colleagues12 modified the early gastric bypass procedure by

replacing the loop with the RNY gastrojejunostomy, which reduced bile reflux andbecame the accepted technique for the anastomosis (Fig. 2). Several years later thejejunoileal bypass was dismissed as an acceptable procedure for weight loss, dueto the increased evidence of serious complications including cirrhosis, interstitialnephritis, and renal and liver failure.13 Fewer surgeons attempted to develop moretechnically challenging gastric bypass procedures, evidenced by the increased useof stapled gastroplasty techniques.14 The 1980s presented an opportunity for bariatricsurgery as more centers became committed to improving the gastric bypass proce-dure.13 Improvements introduced by Torres and colleagues15 included the use ofa vertical gastric pouch along the lesser curvature, which served as a prototype for

Fig. 2. Griffen Roux-en-Y gastric bypass, 1977.


the lesser curve vertical pouches currently used in today’s gastric bypass (Fig. 3). Thedistal RNY was also introduced, describing various lengths of efferent and commonlimbs.13 Other variations introduced by Fobi and colleagues16 in 1998 and Capellaand Capella17 in 1996 included the use of a silastic ring at the gastric pouch to preventdilatation of the gastric stoma. Although the concept behind the ring was intuitive,many surgeons did not accept the use of these devices because of the added riskof erosion.13

In 1991, the National Institutes of Health (NIH) Consensus determined that the RNYand the vertical banded gastroplasty provided a significant benefit to patients withmorbid obesity, and were indicated for patients with a BMI greater than 35 andobesity-related comorbidities or for all patients with a BMI greater than 40.13 However,long-term evaluation of patients who had undergone vertical banded gastroplasty hasshown that frequent postoperative changes in dietary habits, including ingestion ofhigh-calorie soft foods and liquids, leads to weight regain.18 These long-term resultshave largely caused this operation to be abandoned. Nowadays the RNY has emergedand become the gold standard of surgical treatment for clinically severe or morbidobesity because of sustained long-term weight loss, with acceptable short-termand long-term complication rates.Laparoscopy has had a tremendous impact on surgery by reducing perioperative

complications. Morbidly obese patients can be high-risk surgical candidates whoare more vulnerable to cardiopulmonary and wound-related complications, and standto benefit from a less invasive approach.19–22 Although the open RNY procedure hasbeen performed with a relatively low morbidity and mortality rate, the wound-related

Fig. 3. Torres Roux-en-Y gastric bypass with lesser curvature pouch, 1980.


complications have been challenging. The laparoscopic Roux-en-Y gastric bypass(LRNY) has reduced the number of wound complications seen in open bariatricsurgical procedures.23 The development of laparoscopic surgical staplers changedbariatric surgery in the 1990s. The first case series to perform an LRNY was publishedin 1994 by Wittgrove and Clark.24

CURRENT TECHNIQUES OF THE LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS

Despite the technically demanding nature of the LRNY procedure, it has swiftly gainedpopularity over the open technique since its inception in 1994 and has become theprocedure of choice for clinically severe obesity. The totally LRNY procedure requiresthe operating surgeon to have an advanced laparoscopic skill set. The long learningcurve and inexperience with advanced laparoscopic techniques can be a major hitchto this procedure. An alternative to the totally laparoscopic approach is the hand-assisted LRNY. Hand-assisted laparoscopy typically has been used in colorectalsurgery and less frequently in bariatric procedures. Several published studies contain-ing small series of patients in which hand-assisted techniques are used in laparo-scopic gastric banding23 and laparoscopic vertical banded gastroplasty show thebenefits of hand-assisted laparoscopy in bariatrics.25,26

An article in 2000 by Sundbom and Gustavsson27 highlighted the advantages of thehand-assisted technique over the total LRNY approach, as follows: (1) the avoidance ofthe blind abdominal puncture (Veress or trocar-assisted optical view entry, as thesurgeon’s left hand inside the abdomen can guide the introduction of the first trocar);(2) theability of the surgeon’shand todirectly palpate intra-abdominal structures, allow-ing for better anatomic orientation; (3) the surgeon’s hand being used for dissection oftissue as an alternative to conventional laparoscopic instruments such as hook cautery,dissecting instruments, and ultrasonic dissectors; (4) the surgeon’s handbeing used forproper exposure of the surgical field without the use of mechanical retractors. In 2003,a follow-up randomizedclinical trial of hand-assisted laparoscopic versusopenRNY forthe treatment of morbid obesity found that patients did not appear to derive any signif-icant benefit from a hand-assisted LRNY technique in comparison with open surgery,28

as the results did not demonstrate the proposed advantages of laparoscopy over opensurgery of early mobilization, reduction in postoperative pain, and shorter hospitalstay.28 Although the bariatric surgeon who is trying to learn LRNY techniques maybenefit early on from a hand-assisted approach, nonrandomized comparative studieshave recently shown that hand assistance was more expensive than open surgeryand did not improve patient outcome.29

When compared with the open technique the LRNY has been validated in multiplestudies over the span of a decade, being shown to have comparable weight loss,safety, cost effectiveness, and decreased morbidity.23,30,31 The LRNY has beenshown to decrease wound complications, decrease operative blood loss, shortenhospital stay, improve postsurgical quality of life, and decrease the incidence of post-operative pulmonary complications.32–34 However, there is no consensus on oneuniform way that the LRNY is performed. There are variations on whether the Rouxlimb is passed in an antecolic antegastric, antecolic retrogastric, or retrocolic retro-gastric fashion to form the gastrojejunostomy. Multiple techniques of creating the gas-trojejunostomy have been described. Described by Wittgrove and colleagues in1994,24 the transoral circular-stapled technique is the most commonly used methodfor creating the gastrojejunostomy. Other techniques used by surgeons to createthe gastrojejunostomy include the linear-stapled technique, the hand-sewn technique,and the transgastric circular-stapled technique.


Laparoscopic Roux-en-Y Transoral Circular-Stapled Technique

After appropriate patient selection, the patient is brought to the operating room andplaced supine on the operating room table. A time-out is taken to verify the patient’sidentity, procedure, and procedure location. Appropriate preoperative antibiotics aregiven, deep venous thrombosis (DVT) prophylaxis is given, and sequential compres-sion devices are placed to incision. A Foley catheter is optionally placed. Theabdomen is prepped and draped in the usual sterile fashion. At this point in the proce-dure, many different variations are seen based on surgeon preference and training.Examples of this include how the abdominal cavity is accessed, size of ports, locationof ports, and location of the operating surgeon and assistants based on use of split-legextenders (Skytron, Grand Rapids, MI, USA). Themanner in which the authors performthis procedure at their institution is detailed here.A 1:1 mixture of 0.25% marcaine and 1% lidocaine with epinephrine is used to pre-

infiltrate all incision sites. The first incision is made at the left anterior axillary line justsubcostally. A 5-mm Optiview port (Ethicon Endosurgery, Cincinnati, OH) witha 0� laparoscope inserted is used to enter the abdomen under direct vision. Theabdomen is insufflated with carbon dioxide gas to a pressure of 12–18 mm Hg.Once adequate insufflation has been obtained, a 5-mm 45� angled scope is insertedinto the abdomen. Exploratory laparoscopy is then performed. The visualized portionsof the stomach, spleen, colon, small intestine, liver, and gallbladder are all assessed.At this point, a 5-mm port is placed above and to the left of the umbilicus. Additional5-mm and 15-mm ports are placed in the right upper quadrant (Fig. 4). Using abdom-inal graspers, the omentum is retracted cephalad and the ligament of Treitz is identi-fied. The small bowel is measured 50 cm distal to the ligament of Treitz and the smallbowel is transected with a laparoscopic linear stapler (Echelon 60 mm length, 2.5 mmthickness; Ethicon Endosurgery). Then 100 cm of small bowel is measured distal to

Fig. 4. Port site placement for the LRNY.


this and a side-to-side functional end-to-side jejunojejunostomy is created. Using anultrasonic dissector, an enterotomy is made in the Roux limb as well as in the distalportion of the biliopancreatic limb. The linear stapler is used again to create the enter-oenterostomy by placing each end of the stapler in the corresponding enterotomies.Once the stapler is fired, the common opening is closed using a running 2-0 Surgidacsuture with an endoscopic suturing device (EndoStitch, 10 mm; Covidien, Mansfield,MA). A triple-staple technique may also be used to create this anastomosis. Toperform this technique, enterotomies are made as previously described using theultrasonic dissector. A linear stapler is used to create a long enteroenterostomy.The common enterotomy is then closed transversely with the linear stapler. Themesenteric defect between the anastomosis is closed using a running 2-0 Surgidacsuture with an endoscopic suturing device (EndoStitch, 10 mm). The omentum is splitjust to the left of midline to allow for a tension-free path of the Roux limb up to thepouch to create an antecolic, antegastric gastrojejunostomy.

The Nathanson liver retractor (Cook Medical, Bloomington, IN) is inserted througha subxiphoid stab wound to retract the left lateral lobe of the liver (see Fig. 4). The gas-trohepatic ligament is opened in an avascular plane. A linear stapler with bovine peri-cardial reinforcement strips (Peri-strips; Synovis Surgical Innovations, St. Paul, MN) isfired into the lesser curve of the stomach 5 cm distal to the gastroesophageal junction.Prior to this point all tubes are removed from the stomach. A linear stapler (Echelon 60mm length, 3.8 mm thickness) is fired perpendicularly into the lesser curve of thestomach at this same point. The transection is completed up to the angle of His usingan articulating linear stapler with bovine pericardial reinforcement strips (Peri-strips). Agastrotomy is created into the distal end of the pouch through the unreinforced stapleline. The OrVil (EEA OrVil 21 mm Device; Covidien) tube is pulled out through this gas-trotomy and the 15-mm port site. Once the stem of the anvil is visualized, the stringsholding the tube are cut and the tube is removed, leaving the anvil in place. A Lembertsuture is placed on either side of the anvil stem to purse-string the stomach.

Next, the Roux limb is identified. It is brought up to the upper abdomen. Care istaken to make sure that the mesentery is not twisted. An enterotomy is made in theproximal Roux limb. The EEA stapler is introduced through the 15-mm port site. It isdeeply intubated into the Roux limb and brought up to the pouch. The anvil and thestapler are married and fired. The stapler is removed and inspected for two completedonuts of tissue. The anastomosis is visualized through the opening in the Roux limb,and active sites of bleeding are assessed. The proximal portion of the Roux limb isexcised using a linear stapler. The mesentery is divided with the ultrasonic dissector.Lembert sutures are used to reinforce the corners of the gastrojejunostomy. A bowelclamp is placed proximally on the Roux limb, and an intraoperative gastroscopy is per-formed to visualize portions of the esophagus, pouch, anastomosis, and Roux limb forevidence of bleeding. The upper abdomen is filled with water to submerge the gastricpouch and anastomosis simultaneously for an air leak test. The air and the gastro-scope are withdrawn once the anastomosis has been adequately accessed. The irri-gation fluid is suctioned from the abdomen, and a Jackson Pratt drain is placed in theleft upper quadrant. The drain is pulled out through the 5-mm left upper quadrant portsite and secured to the skin using a 3-0 nylon suture. The Roux remnant is placed ina laparoscopic specimen retrieval bag (Endopouch, 10 mm; Ethicon Endosurgery) andpulled out through the 15-mm port site. The Nathanson liver retractor and upperabdominal ports are removed under direct vision. Bleeding from the port sites isassessed. The abdomen is desufflated. A 0-Vicryl suture is used to close the 15-mmport site fascial defect. The skin incisions are closed with 4-0 Monocryl suture and theskin covered with Dermabond.


Laparoscopic Roux-en-Y Linear-Stapled Technique

The LRNY linear-stapled technique is performed in a similar fashion to the previouslydescribed transoral stapled technique, with the exception of the creation of the gastro-jejunostomy. The jejunojejunostomy and gastric pouch are created in a similar fashion.In this technique a 2-layer anastomosis is then created between the pouch and theRoux limb. The outer layer is a running 2-0 Surgidac suture using the endoscopicsuturing device. The inner layer is a partial firing of a linear stapler (Echelon 60 mmlength, 3.5 mm thickness). The gastroscope is passed through the common enterot-omy. The common enterotomy is closed over the top of the gastroscope usinga running 2-0 Polysorb suture. A second layering of 2-0 Surgidac is then performedover the anastomosis in a Lembert fashion. Once both layers are complete, a bowelclamp is placed proximally on the Roux limb and an intraoperative gastroscopy is per-formed. The esophagus, pouch, and proximal Roux limb are visualized. An underwaterair leak test is performed at this point. The air and the gastroscope are withdrawn. Theirrigation fluid is suctioned from the abdomen. The anastomosis is circumferentiallywrapped with omentum, and held in place using 2-0 Surgidac suture.

ANALYZING THE CURRENT TECHNIQUES OF THE LAPAROSCOPIC ROUX-EN-YGASTRIC BYPASS

It is widely apparent that the art or technique of creation of the gastrojejunostomy isone of the most challenging steps during the LRNY. As a result, multiple different tech-niques for creating the gastrojejunostomy have been used by bariatric surgeons tofacilitate this step, as previously discussed. Countless studies and series have re-ported that the main complications using a circular stapler for the gastrojejunostomyare anastomotic leaks and strictures.35 Historical data for the open RNY for morbidobesity indicate that the hand-sewn technique has lower stricture and leak rates incomparison with the circular-stapled technique.36 The LRNY data mimic the historicaldata with the open RNY with regard to the techniques in creating the gastrojejunos-tomy and the stomal stenosis rates (Table 1). Leak rates have been reported from0% to 3% in multiple large LRNY series using the various techniques for creatingthe gastrojejunostomy. A 0% leak rate after 1000 LRNY procedures using either

Table 1Comparison of published data for the incidence of gastrojejunostomy stenosis

Authors, Year No. of Patients Technique Stenosis Number (Percentage)

Wittgrove et al,31 2000 500 CS 8 (1.6%)

Matthews et al,37 2000 48 CS 13 (27.1%)

Champion et al,38 1999 63 LS 4 (6.3%)

Schauer et al,23 2000 275 LS 13 (4.7%)

Higa et al,39 2001 1500 HS 73 (4.9%)

Wittgrove et al,40 2002 1000 CS 40 (4.0%)

DeMaria et al,41 2002 281 LS 18 (6.6%)

Gonzalez et al,42 2003 108 (87/13/8) HS/CS/LS 3 (3%)/4 (31%)/0 (0%)

Carrodeguas et al,43 2006 1291 LS 94 (7.3%)

Leyba et al,44 2008 80 (40/40) CS/LS 7 (17.5%)/1 (2.5%)

Kravetz et al,45 2011 222 (123/99) HS/LS 5 (4.1%)/10 (10.1%)

Abbreviations: CS, circular stapled; HS, hand sewn; LS, linear stapled.


hand-sewn or circular-stapled techniques for the gastrojejunostomy has beenreported.39,46

As we approach a second decade in the era of LRNY, the circular-stapled anasto-mosis technique originally described by Wittgrove and Clark24 is still the mostcommonly used technique for creation of the gastrojejunostomy. As modern tech-nology continues to evolve so does the surgical technology, affording better devicesto assist in difficult problems faced with older devices. The original and early use of thecircular stapler by surgeons was with a 21-mm circular stapler to create the gastroje-junostomy. Since then the 25-mm circular stapler has been developed. Somesurgeons have adopted use of the 25-mm stapler secondary to decreased rates ofstomal stenosis at the gastrojejunostomy. Despite skepticism from some surgeonsto change their approach from the 21-mm to the 25-mm circular stapler in creatingthe gastrojejunostomy, published data would suggest that the use of 25-mm circularstapler shows a decrease in stomal stenosis rates when compared with those of the21-mm circular stapler, with no effect on long-term weight loss (Table 2). Higherpotential for esophageal injury23,32 contributes to the skepticism in passing a larger-diameter transoral anvil, but this has not been demonstrated. Some reports haveshown this potential in passing a 21-mm anvil transorally. However, Wittgrove andClark published a series of more than 1400 patients using the pull-wire technique ofpassing a 21-mm anvil for a circular-stapled anastomosis. This technique was evalu-ated with intraoperative upper endoscopy and water-soluble upper gastrointestinalseries (UGI) on postoperative day 1, with no demonstration of esophageal injuries.53

A transgastric technique of anvil placement to avoid the transoral route has beendescribed, and has been reported to decrease the incidence of wound infectionsand operative times.54,55 Although the circular-stapled technique remains the popularchoice among surgeons for creating the gastrojejunostomy, complications specificallyreported for the circular-stapled technique include stapler malfunction and increasedwound infection rate at the extended abdominal port site where the contaminatedstapler is withdrawn from the abdomen.23

COMPLICATIONS OF LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS SURGERY

As obesity continues to increase nationwide, so does the number of bariatric surgicalprocedures performed. Data from the American Society for Metabolic and BariatricSurgery (ASMBS) estimates that the number of procedures increased from about16,000 in the early 1990s to more than 103,000 in 2003. The ASMBS estimates that220,000 people in the United States had bariatric surgery in 2008. Since the inception

Table 2Comparison of published data for the incidence of gastrojejunostomy stenosis with 21-mmand 25-mm circular stapler

Authors, Year No. of PatientsCircular StaplerSize (mm) Stenosis Number (Percentage)

Nguyen et al,47 2003 185 (114/71) 25/21 10 (8.8%)/19 (26.8%)

Gould et al,48 2006 226 (81/145) 25/21 5 (6.2%)/23 (15.9%)

Fisher et al,49 2007 200 (100/100) 25/21 7 (7%)/17 (17%)

Suggs et al,50 2007 438 (374/64) 25/21 11 (2.9%)/6 (9.4%)

Alasfar et al,51 2009 126 21 29 (23%)

Dolce et al,52 2009 159 21 15 (9.4%)


of LRNY in 1993, it has now become the preferred method and procedure of choice formorbid obesity over its open counterpart. This adoption is mostly attributable to thedecreased complication profile with respect to wound infection and incisional herniarates. Other published data demonstrated further advantages of the laparoscopicapproach with regard to less postoperative pain, decreased operative blood loss,shorter in patient hospital stay, lower pulmonary complications, and an overall betterquality of life.32–34 All surgical procedures include a list of potential complications, andthe LRNY procedure is no exception.

Intestinal Leaks

Intestinal leaks can be fatal, and are likely related to the learning curve associated withadvanced surgical techniques required to perform the procedure. Wittgrove and Clarkreported 11 leaks in their first 500 patients; 9 (3.0%) leaks occurred in the first 300cases, with only 2 (1.0%) leaks in the final 200 cases.56 Leaks can occur at the gastro-jejunostomy, jejunojejunostomy, the bypassed stomach staple line, or the gastricpouch staple line. Leak rates as high as 6.9% have been reported.42 Abdominalpain and peritonitis are not readily found in this group of patients. Clinical findingsare nonspecific and can also represent an acute myocardial infarction or pulmonaryembolus. It is imperative that if a high index of suspicion exists of an intestinal leakthen the appropriate tests be expeditiously performed to guide to the appropriatetherapy. Failure to act quickly could result in the rapid demise of the patient. Diag-nosing intestinal leaks are usually made clinically, by UGI or computed tomography(CT). Greater than 50% of leaks can be missed by the UGI but CT is more reliable.56

Subjective symptoms of a leak include the patient’s feeling of “impending doom,” leftshoulder pain, back pain, pelvic pressure or pain, tenesmus, or worsening abdominalpain. Objective signs are often late and include tachycardia, fever, tachypnea, oliguria,fluid sequestration, hypotension, hypoxia, or shock. Treatment often depends on theclinical situation present. If the leak is well contained and the patient is hemodynam-ically stable, the patient can be treated conservatively with nothing by mouth, percu-taneous drainage, intravenous antibiotics, and intravenous nutrition. If the leak is notwell contained and the patient is hemodynamically stable, laparoscopic exploration iswarranted. If the patient is hemodynamically compromised, open exploration shouldbe performed. During exploration, whether open or laparoscopic, there are 3 princi-ples that must be addressed at the time of exploration: repair of the leak, drain place-ment, and placement of a gastrostomy tube in the bypassed stomach.

Pulmonary Embolism

Multiple series of LRNY procedures have shown that the rates of pulmonary embolism(PE) are less than 1%.57 Despite the low incidence of PE, all precautions should beundertaken for the prevention of a fatal PE. Obesity itself is a risk factor for the devel-opment of DVT and PE. The combination of increased intra-abdominal pressure anda baseline hypercoagulable state places the patient at high risk of DVT and PE.Prevention of DVT includes the use of preoperative heparin or low molecular weightheparin, as well as intraoperative sequential compression devices.

Death

The risk of death associated with the LRNY is reported in most series to be less than1%. Historical data reported from the open RNY experience shows that the two mostsignificant postoperative events that cause mortality are intestinal leak and PE. For thisreason a high index of suspicion must be maintained to prevent this from occurring.


Cholelithiasis

Rapid weight loss is associated with the formation of gallstones as a result of theincreased concentration of cholesterol in the bile. The concentrated bile leads to theformation of sludge with cholesterol crystals that serve as the nidus for gallstoneformation. The best treatment is prevention. Sugerman and colleagues58 showedthat 32% of patients form gallstones after the open RNY. The risk of gallstone forma-tion can be reduced with the addition of prophylactic ursodiol for the first 6 monthspostoperatively, thus reducing the risk to just 2%.58

Stomal Stenosis

Much debate has taken place regarding the complication of stomal stenosis and itscauses. Stomal stenosis, or stricture, is usually at the constructed gastrojejunostomyand not the jejunojejunostomy. As previously discussed, there are multiple techniquesused by surgeons to create the gastrojejunostomy, which include a hand-sewn tech-nique, linear-stapled technique, and circular-stapled technique. Gonzalez andcolleagues42 published an analysis of the 3 techniques and showed that the hand-sewn technique resulted in a lower postoperative stricture rate. There are subtle differ-ences within the same technique that can also contribute to increased incidence ofstomal stenosis, such as the size of circular stapler used (21 mm or 25 mm). Strictureat the gastrojejunostomy site has been reported to occur at as high a rate as 6.6%. Thereason for which stomal stenosis occurs is not well understood. Symptoms includedysphagia, nausea/vomiting, or odynophagia. Diagnosis and treatment are usuallywell tolerated by patients, and consists of upper endoscopy with balloon dilatation.Endoscopic balloon dilatation is usually successful after the first attempt, althoughmultiple dilatations may be necessary to relieve the symptoms associated with stomalstenosis or stricture.

Internal Hernia

Internal hernia is another potential complication after the LRNY procedure, and is re-ported in less than 2% of cases.41 The RNY has 3 potential sites of small intestineherniation: at the jejunojejunostomy, at the area between the Roux limb mesenteryand the transverse colon mesentery (Petersen defect), and at the transverse colonmesentery. The mesocolic defect is created only if the Roux limb is brought retrocolic.This diagnosis can be very difficult to make. The symptoms associated with an internalhernia are vague and most commonly include periumbilical or left-sided crampyabdominal pain. Multiple episodes may occur with only transient symptoms. Patientsmay also present with a small-bowel obstruction. The diagnostic tests of choiceinclude a UGI series or a CT of the abdomen with oral and intravenous contrast. Unfor-tunately, both of these tests will likely be normal if performed after symptoms havesubsided. Treatment is laparoscopic reduction and closure of the hernia defect. Rarelyis open exploration needed unless there is necrotic bowel or loss of domain due todilated small-bowel loops.

Marginal Ulcers

Marginal ulcers can occur early or late, and are located on the jejunal side of the gas-trojejunostomy anastomosis. The rate of ulceration is less than 2%.41 Diagnosis isbased on strong clinical suspicion and an upper endoscopy. Treatment is antacidtherapy using proton-pump inhibitors. Helicobacter pylori infection should also beidentified and treated. Use of tobacco and nonsteroidal anti-inflammatory drugsalso contributes to ulcer formation, and should be discontinued. If treatment should


fail, a UGI should be performed to rule out a gastrogastric fistula with regurgitation ofacid from the excluded stomach. If a gastrogastric fistula is discovered, surgical abla-tion of the gastrogastric fistula may be required.

Bypassed Stomach Dilatation

Acute dilatation of the bypassed stomach can occur as a result of obstruction at thejejunojejunostomy, or may occur spontaneously. Interruption of the nerves of Laterjetresulting in a loss of vagal innervation can also result in dilatation. This complicationcan still be seen in patients despite the preservation of these nerves. Diagnosis canbe made either clinically or radiographically. Signs and symptoms include hiccups,bloating, tympani, tachycardia, and cardiopulmonary compromise. A plain abdominalradiograph may show a large gastric bubble or air-fluid level. If the stomach is fluid-filled without air, the radiograph may not be helpful. Treatment involves needledecompression of the excluded stomach under fluoroscopy. If the problem recurs,percutaneous placement of a gastrostomy tube may be necessary. If these fail orthe patient becomes hemodynamically unstable, placement of a gastrostomy tubein the operating room will be necessary.

Wound Complications

One of the advantages of the laparoscopic approach is the significant decrease inwound complications, including hernias and surgical site infections, in comparisonwith the open RNY. The rate of trocar site hernia is less than 1%, and wound infectionrates are less than 8%.42,59 Diagnosis is made in most instances by physical exami-nation. If the problem arises before any significant weight loss, a CT scan of theabdomen will be required, as the patient’s body habitus may obscure the diagnosis.Treatment of simple wound infections or cellulitis includes antibiotic therapy, and inci-sion and drainage of any fluid collections. Asymptomatic hernias may be postponeduntil the patient’s weight has stabilized to increase the success of the repair. Obviouslyif the hernia is incarcerated, strangulated, or symptomatic, immediate repair isnecessary.

Inadequate Weight Loss

Inadequate weight loss may be a problem after gastric bypass surgery. Wittgrove andClark56 reported that 15% of their patients failed to lose more than 50% of their excessweight after the LRNY. These data correlate well with what is known from the openliterature. The solution to this problem is not easy and potentially adds more risk forthe patient. Twomechanical causes of inadequate weight loss are gastrogastric fistulaand dilated stoma. Diagnosis of these can bemade with a UGI series or esophagogas-troduodenoscopy. Another cause of inadequate weight loss is noncompliance withdietary recommendations. Patients can “eat through” an RNY if they have a dailyintake composed of high fat and carbohydrate foods or drinks. Treatment for a gastro-gastric fistula is surgical. In most cases the reexploration can be performed laparos-copically because of the minimal adhesions left from the initial LRNY. Surgicaltreatment for a dilated stoma has been met with a high failure rate and a higher riskof leak for the patient. The noncompliant patient with inadequate weight loss shouldbe treated with dietetic interventions to help the patient attain more weight loss.The added risk of a second procedure for these patients is not justified if the patient’scompliance is the issue. For those compliant patients who are dissatisfied with theirweight loss, conversion to a malabsorptive procedure should only be done if seriouscomorbidities remain, as the risk of malnutrition is high.


Dumping Syndrome

Gastric dumping is seen in 70% to 76% of RNY patients.60,61 These patients reportsymptoms of abdominal pain and cramping, nausea, diarrhea, lightheadedness, flush-ing, tachycardia, and syncope. These side effects are seen as a beneficial side effectof surgical alteration of the gastrointestinal physiology by some patients, by contrib-uting to decreasing the consumption of energy-dense foods and beverages and ulti-mately encouraging weight loss.61–63 Recently, the etiology of dumping syndrome hasbeen elucidated. It was once thought to be caused by the hyperosmolarity of intestinalcontents accompanied by increased fluid in the intestinal lumen resulting in intestinaldistention, decreased intravascular volume, and hypotension.64 Recent data suggestthat the release of gut peptides, as a result of food bypassing the stomach andentering the small intestines, is responsible for dumping symptoms due to the factthat the symptoms can be countered with a somatostatin analogue.65 Dumping symp-toms decrease with severity and frequency with time, and most symptoms are wellcontrolled by dietary and nutritional changes.63 Dietary modifications found toimprove symptoms include eating small frequent meals and avoiding ingestion offoods with concentrated simple sugars, while increasing intake of foods containingcomplex carbohydrates high in fiber and protein.66 Fifty milligrams of octreotide 30minutes before meals may also decrease symptoms if dietary changes are ineffec-tive.66 Reactive hypoglycemia may cause late dumping, and can be managed withnutritional guidance and alterations or by simply eating small snacks.

Hyperinsulinemic Hypoglycemia

The phenomenon of severe hyperinsulinemic hypoglycemia after RNY is extremelyrare. Also termed nesidioblastosis, this condition is characterized by inappropriatelyelevated insulin concentrations and neuroglycopenia.67,68 Service and colleagues68,69

described nesidioblastosis, a pathologic hyperplasia of pancreatic b cells, as a nonin-sulinoma pancreatogenous hypoglycemia, which is far less common thaninsulinoma as a cause of hyperinsulinemic hypoglycemia. This rare condition of post-prandial neuroglycopenic, hyperinsulinemic, hypoglycemia, and pancreatic nesidio-blastosis has been described only in small series of patients.67,68

Themechanisms underlying this disorder are unclear. One theory is that an intestinalhormone glucagon-like peptide 1 (GLP-1) mediates expansion of pancreatic b cells.70

Others would argue that postprandial hypoglycemia after malabsorptive bariatricsurgery is attributable to a combination of gastric dumping and inappropriatelyincreased insulin secretion, either as a failure to adaptively decrease insulin secretionafter malabsorptive bariatric surgery or as an acquired phenomenon.71

Several different treatment strategies are available, ranging from conservativemedical therapies and diet modification to those of radical surgical treatments.71–73

If debilitating nesidioblastosis occurs, it will likely require another major operation.The result of that second operation could be permanent insulin-dependent diabetesif the entire pancreas is removed or failure to control the attacks of hypoglycemia ifsome pancreas is left in place. Recommendations for pancreatic resection for nesidio-blastosis require approximately 80% to 90% of pancreatic tissue to be removed.74 Aspreviously stated, pancreatic resection comes with its own host of problems. Despitethe reported morbidity of 20% to 40% and mortality of 1% to 5%, and the risk ofdeveloping lifelong diabetes mellitus after pancreatic resection for nesidioblastosis,it can be life saving.75,76 Z’graggen and colleagues77 concluded in a small study of12 patients that the majority of patients with severe postprandial hypoglycemia aftergastric bypass, who are unresponsive to diet modifications, can be controlled by


simple laparoscopic restoration of gastric restriction with surgical placement ofa silastic ring as a first-line surgical treatment before consideration for pancreaticresection.

NUTRITIONAL COMPLICATIONS OF THE ROUX-EN-Y GASTRIC BYPASS

Although routinely performed, the LRNY necessitates the knowledge of potential long-term nutritional metabolic complications and their treatments. The RNY combines thetwo mechanisms of restriction and malabsorption which, in turn, promote effectivelong-term weight loss and improvement of obesity-associated medical conditions.This intervention is fraught with alterations of digestive physiology, leading to nutri-tional and metabolic complications.Routine laboratory studies looking for vitamin and mineral deficiencies in the post-

operative gastric bypass patient should be performed and monitored on a regularbasis. The deficits most frequently observed after the RNY are deficiencies concerningproteins, iron, calcium, vitamin B12, and vitamin D.78–81 Iron deficiency is commonafter RNY and presents primarily as microcytic anemia.82 Various studies have shownan incidence ranging from 20% to 49% of patients.61,83–88 The reduced intake andcommon intolerance of iron-rich foods such as red meat may contribute to the defi-ciency. Coupled with the alterations seen in the changes of digestive physiology ofthe bypassed stomach contributing to the malabsorption of dietary iron, this makesthe etiology of iron deficiency in these patients multifactorial.89–93 Oral iron supple-mentation given as ferrous sulfate, 300 mg 3 times daily, is usually adequate treatmentwhen anemia is identified.82 Iron supplements are sometimes poorly toleratedbecause of constipation and dyspepsia, which may fail to correct the underlyinganemia. In rare instances patients may require intravenous iron infusions for correc-tion.94,95 While these patients require lifelong multivitamin supplementation, ironsupplementation is also recommended for all RNY patients.96 Commercially availabledaily standard multivitamins with iron are not adequate for this population of patientssecondary to the small amount of elemental iron contained within. Two randomizeddouble-blind studies have demonstrated that supplementing with 320 mg of ferroussulfate twice daily prevented iron deficiency anemia.94,97

Playing a vital role in neurologic function and DNA synthesis, vitamin B12 absorptionbegins in the stomach where pepsin and hydrochloric acid cleave it from dietaryintake. Normal vitamin metabolism is altered secondary to the surgical alterations ofthe gastrointestinal anatomy in the RNY. In the duodenum vitamin B12 normally bindsto intrinsic factor released from the stomach, and is absorbed in the terminal ileum.Vitamin B12 deficiency occurs in 26% to 70% of gastric bypass patients.83–85 Eventhough clinically symptomatic B12 deficiency is rare, the ability to maintain adequateserum levels without supplementation is difficult.98,99 While multiple forms of supple-mentation are available including sublingual and nasal sprays, some clinicians recom-mend intramuscular injections. However, several studies have shown that a 300- to500-mg dose of oral vitamin B12 supplementation may be sufficient if tolerated.98,99

Folic acid deficiency rarely causes anemia following the RNY. Essential for reactionsof carbon transfer and playing an important role in DNA synthesis, folic acid must notbe ignored as a potential cause of anemia in the RNY patient. The study of 1067patients by Mallory and Macgregor99 demonstrated that only 1% of RNY patientsdeveloped folate deficiency. Folic acid deficiency has been reported to affect asmany as 9% to 18% of RNY patients at different points in follow-up.83–85 Althoughfolate can be absorbed throughout the entire length of the small intestine, folateabsorption occurs primarily in the upper one-third of the small intestine.85 The


principal cause of folate deficiency appears to be a decreased consumption from die-tary sources, which are easily corrected with vitamin supplementation.88,100 Mostdaily multivitamin tablets contain between 400 and 500 mg of folate. Folate deficiencyshould be avoided with a daily multivitamin, although additional folate supplementa-tion (1 mg/d) should correct deficiencies and is essential for women who becomepregnant after RNY, preventing neural tube defects in infants.101–103

Fat-soluble vitamin deficiencies may also occur after RNY, but more commonlyoccur after the biliopancreatic diversion procedure secondary to the delayed interac-tion of dietary fats with bile salts and pancreatic enzymes from the duodenum. VitaminD and calcium deficiencies are less likely because they are absorbed preferentially inthe jejunum and ileum. Complications related to this deficiency are clinically seen asosteomalacia, and have been reported in several studies after RNY procedures.104,105

Moderate to severe vitamin D deficiency can cause significant muscle aches andfatigue, and is common in the overall population. Daily supplementation of 400 IU ofvitamin D and 1500 mg of elemental calcium is adequate for replacement. Vitamin Adeficiency has also been seen after RNY procedures, clinically recognized as nightblindness. Halverson82 reported vitamin A deficiency in as many as 10% of gastricbypass patients. Oral supplemental therapy is occasionally needed for correction.Thiamine or vitamin B1 is found in a wide variety of foods at low concentrations, and

was the first of the water-soluble vitamins to be described.106 It is not often evaluated;nevertheless, deficiency in this vitamin can occur after malabsorptive procedures suchas the RNY as a result of bypass of the jejunum, where thiamine is primarily absorbed.Vitamin B1 deficiency can also be seen as a result of impaired nutritional intake orfrequent emesis.107,108 Early recognition is essential to initiate appropriate supple-mentation and to avoid potential complications resulting in neurologic deficits. Neuro-logic deficits have been reported as soon as 1 to 3 months after surgery.89–93,109–114

Patients with active neurologic symptoms should be started on parenteral supplemen-tation for 1 to 2 weeks with thiamine (100 mg/d).114,115 An oral preparation of (10 mg/d)

Table 3Nutritional deficiencies with treatment strategies

Nutritional Deficiency Primary Treatment Secondary Treatment

Vitamin B1 (thiamine) Parenteral thiamine (100 mg/d)for 7–14 d

Oral preparation of thiamine(10 mg/d)

Vitamin B12 (cobalamin) Oral crystalline B12, 350 mg/d 1000–2000 mg/2–3 mointramuscular

Folic acid Oral folate, 400 mg/d (includedin multivitamin)

Oral folate, 1000 mg/d

Vitamin A Oral vitamin A, 5000–10,000 IU/d Oral vitamin A, 50,000 IU/d

Iron Ferrous sulfate 300 mg 2–3 times/d,taken with vitamin C

Parenteral iron administration

Protein malnutrition Enteral protein supplements Enteral or parenteral nutrition;reversal of surgical procedure

Calcium/vitamin D Calcium citrate, 1200–2000 mg,oral vitamin D, 50,000 IU/d

Calcitriol oral vitamin D,1000 IU/d

Data from Heber D, Greenway F, Kaplan L, et al. Endocrine and nutritional management of thepostbariatric surgery patient: an Endocrine Society Clinical Practice Guideline. J Clin EndocrinolMetab 2010;95(11):4823–43.


can be used following parenteral supplementation until neurologic symptomsresolve.116–118 Severe thiamine deficiency typically occurs in patients after bariatricsurgery, who develop intractable vomiting due to stomal stenosis. It is importantthat unrelenting vomiting be evaluated and resolved aggressively to prevent thiscomplication.The anatomic changes imposed by bariatric or malabsorptive surgery increase the

risk for various vitamin and mineral deficiencies that occur as soon as the first yearafter surgery.59,97,119–124 Malabsorptive procedures can be associated with micronu-trient and macronutrient deficiencies, and require lifelong supplementation and moni-toring.125,126 Patients with existing osteoporosis and heavy menstruation whoundergo bariatric surgery are at increased risk, and prophylactic supplementationshould be considered.119,127–129 Proper screening and supplementation of defi-ciencies with a multivitamin-mineral, iron, vitamin B12, or calcium with vitamin D isroutinely conducted. Best-practice guidelines recently published recommend a dailymultivitamin and calcium supplementation with added vitamin D for all weight-losssurgery patients.130 Table 3 highlights the list of common nutritional deficienciesand treatment plans seen in the RNY patient.

SUMMARY

Morbidobesity hasbecomeapandemicproblemof this century, andhasaccelerated tothe forefront of leading causes of preventable death. The trend for bariatric surgery hasfollowed this trend because it has proved to be a valid treatment strategy for reductionandeliminationof obesity-relateddiseasesand long-termsustainableweight loss.Overthe past 60 years bariatric surgery has embraced surgical innovation, which has refinedtechniques to offer multiple unique and effective surgical treatment options. As in mostfields of surgery, the minimally invasive or laparoscopic techniques have replaced theopen procedures. Despite the need for advanced technical skills to achieve successand assure adequate patient safety, bariatric surgery has been no exception to a newgeneration of minimally invasive surgical techniques. Published data of case series,improvements in surgical technology, surgical training, and surgeon preference areall factors that play a critical role in the small intricacies and variations of the procedure.The largest variable in technical aspects of the LRNY is the creation and size of the gas-trojejunostomy. These factors contribute to the lack of a single universal way in whichthe LRNY is performed.Regardless of the variations in technique, over thepast 20 yearsthe LRNY has remained the gold standard for the surgical treatment of clinically severeor morbid obesity, with relatively low morbidity and mortality.

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