RYGB

Principles:

• Small (15-30mL) pouch anastomosed to 75-150cm Roux limb
  • Pouch is restrictive
  • Bypass malabsorptive - means better weight loss results than purely restrictive procedures
• Anastomoses can be done stapled or sewn according to preference
• All mesenteric defects should be closed
  • Reduces the incidence of internal hernias by 4-fold
• Roux limb
  • Antecolic Roux limb is easier than retrocolic and reduces the number of mesenteric defects
• Length of common channel is important to determine level of malabsorptive weight loss
  • Some say longer limb, up to 150cm, for patients with BMI > 50
• Expected weight loss after two years is approx 70%
  • Aim 60-80% excess weight loss

Technique

• Lithotomy, reverse Trendelenburg
• Same ports as for sleeve gastrectomy
• Nathanson retractor
• Create pouch
  • Clear angle of His by dividing short gastrics from spleen
  • Enter lesser sac 7cm distal to GOJ, along lesser curvature
  • Staple transversely across stomach at this level
• Plan reconstruction
  • Retract omentum and transverse colon cephalad - visualise ligament of Treitz, look for IMV
  • Follow jejunum distally for 50-150cm (100cm at Austin)
  • Staple across bowel at this point, with assistant holding on to proximal limb
• Create jejunojejunal anastomosis
  • Follow the common channel (distal limb) 100cm distally
  • Stay suture this piece of bowel to the end of BP limb, which assistant is still holding
  • Create a stapled side-to-side anastomosis, suturing the stapler holes again in purse-string fashion
• Create gastrojejunal anastomosis
  • Take the proximal end of common channel (free end) up to stomach, most likely antecolic
  • Place bougie down to distal end of pouch
  • Create holes in both pouch and jejunum to admit stapler, and make a side-to-side anastomosis, with slight j-loop
  • Close the staple holes with front and back sutures
• Close mesenteric and Petersen's defects with Glubran (can also suture)

Post-op

• Sips water 4/24, then bariatric free fluids for 2/52, then pureed for 2/52, then soft diet for 2/52, then normal diet
• No routine inpatient bloods
• Bariatric bloods at clinic F/U
• SOOB for all meals day 1 post-op
• Enoxaparin 6/24 post

Outcomes:

• At 10 years, expect to have lost about 58% excess weight; 46% remission of HTN and hypercholesterolaemia and 58% remission of diabetes; 87% had nutritional deficiencies

Complications

• Early (<30 days)
  • Leak - see 'sleeve gastrectomy'
    • Common at gastric pouch or gastroenterostomy, uncommon at enteroenterostomy
  • Obstruction
    • Internal hernia

• Peterson's space is between an antecolic Roux limb and the transverse colon
• Mesojejunal ('Brolin's') space occurs under the distal part of the BP limb, where it has been detached and brought down to the J-J anastomosis
• The transverse mesocolic space occurs in retrocolic Roux limbs
• 'Classic bypass torsion' occurs when the entero-enterostomy prolapses through Petersen's space and creates a torsion in the mesentery, which can be symptomatic for weeks prior to presentation
• CT with PO contrast is the best study
• Any dilated loops of bowel on the right are concerning. Look particularly for a mesenteric twist or volvulus of the Roux limb. The danger is that proximal distension of the stomach can rupture the staple line.
• Generally, most patients with SBO after RYGB need a re-operation
• Diagnostic laparoscopy - run bowel from proximal to distal or vice versa. Reduce torsion either by pushing/pulling back through from right to left. Remember to close mesenteric defect with non-absorbable suture.

• Adhesive
• E-E anastomosis
• Obstructed BP limb
  • Closed loop obstruction between the obstructing point and duodenal stump
  • High intra-luminal pressures can cause elevated LFTs/lipase, and eventually necrosis of the loop
  • Can see epigastric pain, upper abdominal mass and high lipase

• PE 1%
• Pneumonia
• Bleeding
• Acute distal gastric dilatation
• Infection

• Late
  • Marginal ulcer (2-10%)
    • Not related to acid according to AC - related to ischaemia - although UTD just says caused by acid injuring jejunum
    • Risk factors - H pylori, larger pouch size (presumably leaves more parietal cells secreting acid), smoking, tenuous blood supply of g-j, excess acid production in gastric pouch due to gastro-gastric fistula, NSAID use, diabetes
    • Occurs on jejunal side of anastomosis
    • Presentation
      • Commonly continuous 'boring' epigastric pain
      • Can also present with perforation or chronic bleeding
      • Complication - fistula to lower part of stomach, which provides more acid and thus exacerbates the ulcer
      • Also leads to structure at G-J
    • Management
      • Medical is usually successful - PPI sulfate (for minimum three months), avoid NSAIDs - for 3-6 months
      • If bleeding - usual endoscopic treatment. UTD says consider embolization - I'm not sure if this is a good idea
      • Exclude gastro-gastric fistula
      • Operation for complication - options are gastrojejunostomy revision, vagotomy, subtotal/total gastrectomy, and reversal to normal anatomy
      • QUIT SMOKING
      • Consider revision of limb if resistant to medical treatment
  • Stomal stenosis
    • Occurs at the gastrojejunostomy
    • More common after stapled join
    • More common with NSAID use and smoking
    • Usually manifests at 4-6 weeks post-op as progressive intolerance to solids and then liquids
    • Usually treated successfully with balloon dilation. Doesn't require a reoperation unless there is a marginal ulcer.
  • Dumping syndrome
    • See 'gastrectomy' complications
  • Obstruction - see above
    • Internal hernia
  • Incisional hernia
  • Cholecystitis
  • Vitamin and mineral deficiencies
    • Wernicke's encephalopathy - particularly seen with severe vomiting - vitamin B1 (thiamine) deficiency
    • Iron deficiency (since iron is absorbed in duodenum and proximal jejunum). Usually managed with oral iron (the gluconate form is best absorbed in a non-acid environment).
    • B12 deficiency (15-20%). Rarely causes anaemia. Inefficient absorption due to delayed mixing with intrinsic factor, so can develop despite oral supplementation. Need to use a route other than oral.
  • Weight regain
    • Can try endoscopic suturing of the gastroenterostomy, to deliberately reduce it in size
  • Hypoglycaemia