Gastric Bypass

Roux-en-Y gastric bypass (RYGB) is a permanent procedure that combines both restriction and malabsorption approaches. In this procedure, a surgeon creates a small stomach pouch, connecting it to the middle of the small intestine through bypassing the larger portion of the stomach and upper part of the small intestine. 

RYGB can be done as an open surgery, with a large cut to reach your stomach. Or it can be done as a laparoscopic RYGB, using a lighted tube with a tiny camera, called a laparoscope. This tool is pushed into your abdomen through several small cuts. Your doctor may prefer to do a laparoscopic procedure instead of open surgery because it generally means you don't stay in the hospital as long and recover more quickly. You also may have less pain, smaller scars, and less risk of getting a hernia or infection.

The American Society for Bariatric Surgery and the National Institutes of Health consider Roux-en-Y gastric bypass as the current gold standard in surgical weight loss procedures.

Like any surgery, the RYGB procedure carries some risks:

• Internal bleeding
• Infection
• Potentially life-threatening blood clots in the legs that can travel to the heart and lungs
• Respiratory problems
• Leaks from internal and external incision sites
• Death

Long-term complications related to RYGB surgery may include: 

• Malnutrition, especially if you don't take your prescribed vitamins and minerals daily for the rest of your life
• Iron and calcium deficiencies
• Left untreated, severe and potentially fatal vitamin and protein deficiencies. These are caused by poor absorption of nutrients, which can lead to diseases rarely seen in the developed world. Such diseases include pellagra, a dangerous niacin deficiency that can also cause dementia; beriberi, a thiamine deficiency that can cause irreversible nerve damage and heart failure; and kwashiorkor, a severe, life-threatening form of malnutrition.
• Gastric "dumping," which can cause vomiting and diarrhea, rapid heartbeat, flushing, fainting, and other unpleasant symptoms after eating
• Narrowing of the sites where intestines are joined
• Staple-line failure, where the pouch was created
• Dangerous internal hernias
• Need for additional operations because of problems such as a stretched pouch or separated stitches
• Failure to lose enough weight if you snack on high-calorie foods and don't exercise 

There may be other risks, depending upon your specific medical condition. Be sure to discuss any concerns with your doctor before the procedure.

It's important that your weight-loss surgery be arranged at a qualified bariatric center, where you will complete an extensive program before surgery. Your doctor can obtain a referral from the American Society for Metabolic and Bariatric Surgery (ASMBS).

• Your doctor will typically test you for nutritional deficiencies and prescribe supplements to correct any problems before the operation. Your surgeon may ask you to have tests and visits with other health care providers before surgery.
• Because smoking slows recovery and increases risks of surgery, your doctor may suggest you stop smoking for good several weeks before surgery. Tell your doctor or nurse if you need help quitting.
• You'll want to check with your health insurance provider to make sure the procedure is covered.
• Let your doctor know about any prescription or over-the-counter drugs, vitamins, and herbs you are taking. In the week before surgery you may be asked to stop taking aspirin, ibuprofen (Advil, Motrin), vitamin E, warfarin (Coumadin), and any other blood-thinning drugs. Ask what drugs you can take on the day of your surgery.
• Let your doctor know if you have had any trouble with anesthesia in the past.

With either open or laparoscopic RYGB surgery, you will be given general anesthesia before the procedure. Initially your doctors will start an IV to deliver medications to help you relax. Your anesthesiologist will use a drug or combination of drugs to control pain and make you unaware of the procedure.

When you reach the operating room, your medical team will use routine monitoring equipment throughout the procedure or longer, depending on your health conditions.

The surgery to create the stomach pouch and the bypass usually takes several hours.

You may stay in the hospital for one or two days after the procedure. You will typically only have liquids or puréed foods for at least three weeks after surgery. You may have a catheter, or tube, from the larger bypassed part of your stomach that will come out of your side and drain excess fluids from your abdomen for four or more weeks.

Your doctor may slowly add soft food and then regular food to your diet about a month after surgery. Your doctor will likely tell you to chew slowly and completely and not to drink 30 minutes before or after you eat food.

Talk with your doctor about proper wound care, the type of pain-relieving drugs that are safe to take, and when you can resume normal activities. Your surgeon will tell you how often to change the dressing on your incision. 

Tell your doctor right away if you develop a fever or if your wound becomes painful or hot to the touch or has a foul-smelling drainage. Also look for any coughing or difficulty breathing, vomiting and diarrhea, pain in the abdomen, chest, shoulder, or legs, or any other unusual symptoms.

Your initial weight-loss may occur quickly, so it's important to get all of the nutrition and vitamins you need as you recover. Your doctor will prescribe certain vitamin and mineral supplements that your body may no longer absorb well from food alone.

The ASMBS recommends that you take the following supplements to prevent nutritional deficiencies after recovery from RYGB surgery:

• Daily vitamin D and calcium supplements. Vitamin D deficiency is common in people who have had this kind of gastric bypass. Multivitamins containing 1,200 mg of daily calcium citrate and 400 to 800 IU of vitamin D don't appear to provide enough protection for bone health, studies suggest. Some experts have had success stopping bone loss by increasing vitamin D intake to 1,600 to 2,000 IU daily.
• Multivitamins. You should take a daily multivitamin that contains 200 percent of the daily values. Wait two hours to take a calcium supplement after your multivitamin.
• Vitamin B₁₂ supplements. Doctors recommend vitamin B₁₂ supplementation for all weight-loss surgery patients to help prevent bone fractures. You may need to give yourself B₁₂ injections for the rest of your life.
• Oral vitamin D supplementation if a deficiency is detected. Your doctor may prescribe 50,000 IU of vitamin D2 taken orally once a week for eight weeks.
• Iron supplements. Research suggests that after RGBY surgery, the amount of iron contained in a standard multivitamin may not be enough to prevent anemia. Teens and menstruating women may require the amount of iron found in two multivitamins, along with 50 to 100 mg of elemental iron a day. The ASMBS also recommends supplemental vitamin C, among other supplements, to make it easier for the body to absorb iron. You should check with your doctor for the recommended dose for you.

You may experience body aches, dry skin, mood changes, and hair thinning and loss during this time, as well as feel tired and cold. As your weight stabilizes, these problems should go away. Know that weight loss may slow down after the first year.

Along with follow-up appointments with your doctor and surgeon, you will likely see a nutritionist or dietitian who will teach you how and what to eat with your reduced stomach size. You may also need to visit with a psychologist to help you deal with the feelings and concerns over your changed lifestyle.

Because nutritional deficiencies are so common after this surgery, experts recommend that your blood be tested every six months for the rest of your life to ensure that you are getting the right amount of vitamins and minerals.