What is Roux en y gastric bypass (RYGB) SURGERY?
This is the second most commonly performed bariatric surgery worldwide. A small pouch is created in the upper part of stomach. Jejunum is divided 50 to 150 cm beyond the duodenojejunal junction. This divided jejunum is anastomosed (attached) to gastric pouch in a roux en y fashion.
Since part of small intestine is bypassed, undigested food reaches distal ileum (last part of small intestine) rapidly leading to increase in GLP1 & Peptide YY (Satiety hormones). Proximal intestine (duodenum and proximal jejunum) is bypassed, leading to lowered anti incretin hormones. There will be more than 200 hormonal changes after surgery. These hormonal changes reduce appetite, increase energy expenditure and reset the ‘fat mass’ to a lower level, resulting in long lasting, effective weight loss. Same hormonal changes are responsible for long lasting type 2 diabetes remission. Anti incretins act against insulin. As levels of these hormones come down, insulin resistance comes down. Since GLP 1 hormone is increased, insulin production increases and insulin resistance comes down. Diversion of biliopancreatic juices also contributes to the metabolic effects of this surgery. Role of restriction or malabsorption of food is secondary, in inducing weight loss or diabetes remission.
RYGB is relatively simple and safe surgery. Since bypassed segment of intestine is less than 200 cm, malabsorption risk is less. There is no risk of acid reflux into esophagus.
Stomach is not removed in RYGB surgery. So there is ‘at risk gastric remnant’. If you develop ulcer or cancer in remnant stomach, it is not possible to monitor by upper gastrointestinal endoscopy. It is not possible to access common bile duct (pipe below liver) by endoscopy. Since duodenum (1st part of intestine) is bypassed, risk of calcium and iron deficiencies is high. Since pylorus (valve below stomach controlling food output) is bypassed, risk of dumping syndrome (dumping of nutrients into intestine leading to fluctuations in blood glucose) is high. Also risk of narrowing of anastomosis (attachment between gastric pouch and jejunum), marginal ulcers (ulcers at the anastomosis) and internal hernias is high after this surgery. Weight regain and diabetes recurrence is less than that of gastric sleeve surgery. But more than that of sleeve + bypass combination surgeries. These patients may need revision bariatric surgery to induce further hormonal changes necessary for weight loss and diabetes remission. Most of these limitations are addressed by combining sleeve with bypass (Sleeve + Bypass).
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Laparoscopic ROUX EN Y Gastric Bypass
(Drawn by Dr. V. Amar)
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