Laparoscopic Roux-en-Y Gastric Bypass with circular-stapled gastrojejunostomy and linear-stapled jejunojejunostomy

Morbid Obesity with a body mass index (BMI) more than 40 kg/m2 or (BMI more than 35 with a significant co-morbid condition

Any patient whose physical condition is such that they are unable to tolerate a general anesthetic or have behavioral or nutritional impairments that would preclude a bariatric operation

The patient is placed in supine position with arms out and a foot-board in place. Pressure points are adequately padded and protected to prevent pressure related injuries.

Prior to undergoing bariatric surgery must meet indications for bariatric surgery, and complete an evaluation by a multidisciplinary team to obtain medical, nutritional and psychological clearance. Typical workup includes complete blood count, comprehensive metabolic panel, vitamin levels, electrocardiogram, chest radiographs. An evaluation of the upper gastrointestinal tract with either contrast studies or endoscopy is often performed. Additional tests such as expert consultations or sleep studies to exclude sleep apnea are obtained as indicated.

It is important the crura of the diaphragm to rule out a hiatal hernia. The gastroesophagel junction is identified to create a 30 ml pouch and not accidentally transect the esophagus. The ligament of Treitz is important to identify because the bowel is measured from there to create the various limb lengths.

The advantages of this operation include Very effective weight loss and resolution or improvement of comorbid conditions such as diabetes mellitus type 2, gastroesophageal reflux disease, sleep apnea and hypertension.
Disadvantages include dumping symptoms, chances of marginal ulceration, bowel obstruction and nutritional deficiencies.

The major complications of bariatric surgery include: leaks, venous thromboembolism, bleeding requiring transfusion, stricture, nutritional deficiencies and mortality. The complication rate of this surgery, when performed at high volume centers, is low.

Ranjan Sudan (Medtronics and GORE consultant)
Nova Szoka (Novadek consultant)

author contact: ranjan.sudan@dm.duke.edu

1. Tichansky DS, Sudan R. Ch 7. Preoperative Care of the Bariatric Patient. In: Nguyen NT, Rosenthal R, Ponce J, Morton J, Blackstone R (eds). The ASMBS Textbook of Bariatric Surgery, Vol. 1. New York, NY: Springer. 2014
2. Sudan R, Winegar D, Thomas S, Morton J. Influence of ethnicity on the efficacy and utilization of bariatric surgery in the United States. Journal of Gastrointestinal Surgery, 18(1):130-6, 2014 Jan. DOI: 10.1007/s11605-013-2368-1 (Epub 2013 Oct 8).
3. Sudan R; Nguyen N, Hutter M; Brethauer S; Ponce J; Morton J. Morbidity Mortality and Weight Loss Outcomes after Reoperative Bariatric Surgery in the USA. Journal of Gastrointestinal Surgery. J Gastrointest Surg. 2014 Sep 4.Epub 2015 Jan PMID:25186073