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Roux-en-Y gastric bypass
The Roux-en-Y gastric bypass was developed by Dr. Edward E. Mason
of the University of Iowa, and is based on his observation that
women who had undergone partial gastrectomy for peptic ulcer disease
tended to remain underweight after the surgery. Subsequent modifications
to the procedure have included use of the Roux-en-Y technique to
avoid loop gastroenterostomy and the bile reflux that may ensue
(Figure 5). As well, the Roux limb has been lengthened to 100-150
cm, which has served to shorten the common limb to 200-250 cm, achieving
a greater element of malabsorption and improved weight loss. The
gastric bypass differs from the BPD in that the size of the gastric
pouch is smaller (10-15 mL vs 100-200 mL) and that the common channel
is longer (~250 cm vs 75 cm). Finally, the use of retrocolic and
retrogastric routing of the gastrojejunostomy eases the technical
difficulties of the procedure and improves long-term weight management
results.
Complications include leaks at the junction
of the stomach and small intestine (anastomotic leaks) and late
complications such as narrowing of the stoma, anemia and vitamin
B12 deficiency. Since the food stream bypasses the duodenum, the
primary site of calcium absorption, the possibility of calcium deficiency
exists, and all patients should take supplemental calcium to forestall
this.
Dumping syndrome can occur when the patient
eats refined sugar - symptoms include rapid heartbeat, nausea, tremor
and feeling faint, sometimes followed by diarrhea. Since no one
likes these kinds of sensations, people who've undergone gastric
bypass surgery tend to avoid sweets, a circumstance that further
helps them in their efforts to lose weight.
Does
bariatric surgery reduce mortality?
Numerous studies have found a decreased mortality risk in individuals
who have lost weight after bariatric surgery. We reported for the
first time in 2004 that permanent weight loss reduced the relative
risk (RR) of death by 89% compared to no surgery.7 In this study,
we followed 1,035 of our patients after bariatric surgery at the
McGill University Health Centre (MUHC). We compared their outcomes
to a control group of 5,746 individuals who didn't have weight loss
surgery (and thus stayed morbidly obese). The absolute mortality
rate during the 5-year follow-up was 0.7% in the bariatric surgery
group compared with 6.2% in controls.
The SOS study showed similar results; the
surgery group had a risk of death that was reduced by 20-30% thanks
to fewer heart attacks and cancers.2 A study from Australia, looking
at laparoscopic adjustable gastric banding, found a 72% lower hazard
of death in the treated patients compared to controls.8 Researchers
from the University of Padua, Italy, also evaluated long-term data
from obese patients who had undergone adjustable gastric banding
- and report a 62% reduction in the RR of death in the surgery group.9
Concentrating on gastric bypass surgery, a collaborative research
project conducted in Utah found a 40% reduction in mortality in
treated subjects, with fewer deaths from heart attacks, diabetes
and cancer.10
What's
the current status of bariatric surgery in Canada?
Canadian general surgeons have only recently become involved in
bariatric surgery, and just a handful use the laparoscopic technique.
In 2004, there were approximately 1,800 weight loss surgical procedures
done in Canada,11,12 treating < 1% of morbidly obese individuals
in this country. Of these, 80% were open procedures and 20% were
done laparoscopically (7% gastric banding, 13% Roux-en-Y gastric
bypass).
Up until February 2002, all bariatric surgery
in Canada was performed via standard open incision. However, this
leads to wound infection and/or incisional hernia in 1 out of every
4 patients. The only way to eliminate such complications is to avoid
making a large cut down the middle of the belly, i.e. use a laparoscopic
approach. We performed the first laparoscopic Roux-en-Y isolated
gastric bypass at the MUHC on February 8, 2002. To date, the Bariatric
Surgery Section of the Division of General Surgery, MUHC, has completed
over 3,400 weight loss surgical procedures - the last 1,000 by laparoscopic
approach.
Key points
- bariatric surgery is an important
treatment option for morbid obesity
- surgically induced sustained weight loss
in patients with this disease decreases morbidity and mortality
- it also reduces the risk of developing
associated health conditions
- as a result, healthcare utilization and
direct healthcare costs are decreased.
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