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The Roux N Y- the "gold standard" procedure...

The Roux n Y

The Roux n y is considered the "gold standard" when considering all of the weight loss surgery procedures. It appears to have the right combination of restrictive and malabsorptive properties to not only make it effective as a procedure, but long term weight loss is often maintained.

This is in fact, the procedure I had done. 

This is the most commonly performed operation for weight loss in the USA, with 140,000 performed in the year 2006 alone. This number steadily increasing. 

The procedure was developed by Dr Mason and Ito in the 1960’s. They noticed that patients who had undergone a partial gastrectomy (removal of stomach) for severe ulcers or cancer. They noticed that these particular patients experienced profound weight loss. Over several decades, the operation was modified to it’s present form.

Initially, the operation had a loop bypass and a much larger stomach.  Bile reflux occurred due to the loop configuration. The operation was further modified to reflect the Roux N Y configuration; meaning that a limb of the intestine is connected to a very small stomach pouch. This prevents bile from refluxing into the esophagus. 

In creation of this small pouch- which is sectioned off from the rest of the stomach and secured with several rows of staples. The remaining stomach and the first segment of ileum (small intestine) are bypassed.  There is some malabsorption, but macronutrients and protein are absorbed, albeit in smaller amounts. The section of intestine that is bypassed is where calcium and iron absorption takes place. Vitamins B-1 and B-12  are absorbed here as well. It is thereby imperative that life-long vitamin and mineral supplementation becomes an intricate part of a post bariatric patient’s regime. As I emphasize several times throughout this website- lifelong medical follow up is imperative and necessary. It is also important to let any health care provider you are cared for by know that you have had this type of surgery. In many patients, especially women, bone mineral density can plummet after weight loss surgery. This leaves many women vulnerable to osteopaenia and fractures.

Several well constructed and well controlled studies have shown the Roux NY to have quite durable weight loss over time and a marked improvement in previous co-morbidities such as diabetes, hypertension and sleep apnea. 

There are interesting changes that take place in the behaviour of the Roux N Y patients.  Almost all patients have a marked reduction in hunger. Fullness occurs quickly. Many patients make healthier food choices and often state that they do not feel hungry. I do remember this very clearly. In the first 18 months or so after my surgery, there were times where I felt so little hunger, that I often “forgot” to eat. This was a bad habit I fell into oftentimes during long hours at work when I was seeing dozens of patients. Oftentimes a short break could be disastrous in terms of the speed and momentum I needed to keep to keep my day going smoothly. It was extremely powerful at first- having such incredible control over my hunger for the first time ever in my life.  I do not however, recommend allowing yourself to fell into this pattern- no matter how tempting. The potentially long term health effects can be very devastating,

These alterations in eating patterns and startling behavioural changes are due in part to changes in the levels of many complex, interacting hormones (such as ghrelin and GIP).   Also, the neural signals that are received from the now very small stomach send  different messages to the brain. Satiety signals now appear much quicker than they had previously when the stomach was much larger and overeating was a common occurrence.  

The risk of dying from this procedure is at it’s highest immediately post op. Death from complications of this operation are about  0.2% to 0.5%  

Some early complications of the Roux N Y that can occur: 

Anastomatic leak: ( usually in the operating room, the surgeon will infuse something called methylene blue into the stomach pouch via the mouth. If the methylene blue leaks out into the abdominal cavity- then he/she knows that there is a leak that he/she must locate and correct. Also, on post op day one, you will swallow some horrible tasting radiopaque liquid and you will then have an abdominal x-ray  to check for any leaks.) If a leak is unrecognized, it can lead rapidly to peritonitis and death.

Pulmonary embolism: This is by far, the most catastrophic complication. The highest danger point truly is on the OR table. If you make it to recovery, your chances have fallen by about 75%. If you get up and are walking within 24 hours, you chances of a PE are diminished even further. Many surgeons use special boots on post op day one that alternately inflate and deflate to keep blood from stagnating in the legs and thereby increasing the chances of a PE.  

Wound infection:    Unfortunately, the obese are typically poor healers. When I was still in practice as a midwife, and I rounded on my ladies some of whom had C-sections- the ones who were very obese had a tougher time healing and were more likely to herniate and have wound de-hisence(when the wound edges start coming apart and the whole thing starts to open). Also, unfortunately, many obese have the co-morbidity of diabetes as well and this will also contribute to poor wound healing. Treatments include draining the wound, treating with antibiotics and going back to the OR to re-close the would. It is rarely a deadly complication- but it does make a post op course more annoying and difficult. This is quite rare with laprascopic surgery due to the size of the incisions (they are much smaller). 

Some later complications that can occur:

Micronutrient deficiencies: Because the duodenum is by-passed ( the duodenum is the opening from the stomach to the first part of the small intestine which allows food to leave the stomach after it is churned up in the stomach with hydrochloric acid- it enters the small intestine for the next phase of digestion)  is bypassed, this can occur and grow worse over time. The duodenum is what is responsible for the absorption of calcium, iron as well as B-12.

Bowel obstruction: Whenever the GI tract is altered, there is always a possibility for the formation of scar tissue and adhesions. There are times, albeit it is fairly rare when the scar tissue can cause bowel obstruction. An internal hernia can also cause a bowel obstruction, as well as a twisted loop of bowel (volvulus). When bowel is obstructed, blood flow can be cut off and tissue can become necrotic (start dying). This is very dangerous if it is not reversed quickly. It is imperative that if you have severe abdominal pain and/or tenderness, you cannot pass gas or your bowel movements stop- you must contact your doctor or go immediately to the nearest ER and be sure that the ER staff is aware that you have had gastric bypass surgery. Treatment is a trip back to the OR to reverse the obstruction.

Stomal stenosis: This is when the opening between the stomach pouch and the intestine develops a small “collar” of scar tissue on the inside.  usually this develops over time and the opening gradually becomes smaller and smaller and this makes the passage of food more and more difficult. Sometimes the stoma becomes completely sealed over.  Again, this is a situation that must be corrected ASAP in order to avoid other complications. Treatment involves passage of an endoscope (via the mouth) with a special attachment on the end of it that widens the stoma to it’s original size and snips away the scar tissue. Recovery time is usually minimal and most people are back to their normal activities.

Below is a schematic of the Roux N Y. Note the stomach pouch which attaches to a piece of intestine. The rest of the stomach sits unused  and the duodenum is completely bypassed.

Below is a shot of an insufflated abdomen in the OR with the 6 trocars already inserted. The trocar is what the surgeon passes the precision instruments used in the laprascopic Roux N Y. Don' get too freaked by this- remember- you are under general anaesthesia when this is happening- you won't remember a thing.

Here are some links to check out further:

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