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Roux-N-Y Gastrik By-Pass

Roux-N-Y Gastrik By-Pass (RNYGP) is currently the most common bariatric surgery performed all over the world, especially in the USA. (In the redcent year, the rate of
tube stomach surgery has increased and almost …

Roux-N-Y gastric by-pass (RNYGP) is currently the most common type of obesity surgeon in the world, especially in the USA. (In the recent year, the rate of tube stomach surgery has increased and is almost performed as many as RNYGP.) The indication for gastric bypass surgery is the same as for all other bariatric surgeries.

This procedure is preferably performed for patients who eat less but has a very high-calorie diet, called sweet eater. Since reducing the size of the stomach alone will not result in sufficient weight loss, a procedure to restrict the absorption should be added.

It is not performed for patients with chronic intestinal disorders, because it will be an intervention also intended for small intestines, unlike sleeve gastrectomy.

How is Roux-en-Y gastric bypass carried out?

As in other types of bariatric surgery, gastric bypass is performed laparoscopically as well, in other words by using the closed technique. We see all the benefits of laparoscopic surgery in bariatric surgeries as well, such as an extremely low postoperative pain, a good cosmetic result and early mobilization.

It is a procedure lasting approximately between 120 and 180 minutes. The Roux-en-Y gastric bypass procedure is performed at 3 stages;

1- In the first stage, the stomach is cut with the help of special equipment and a small stomach is created. This is called the stomach pouch. The volume of this stomach pouch is about 35-50 cc. The volume of a normal stomach is between 800-1000 cc, thereby the stomach volume is reduced by over 95%.

2- Since the stomach portion of 95% is closed to the food passage after the new small stomach pouch is formed, a new way is needed to provide the passage of foods into the intestines.

To do that, the small intestines are cut about 50-75 cm from the beginning, and the tip going downward is pulled up and anastomosed to the new stomach with special equipment. Thus, the old stomach and the small intestine of 75 cm remain passive and never come across food.

3- A large portion of the stomach and the first portion of the small intestine continue to produce liquid, even more importantly, bile and pancreatic enzymes, even if it is closed to food passage.

Therefore, in order to keep the vital fluids flowing into this closed portion within the body, the closed tip of the small intestine is anastomosed to the small stomach pouch and to the lower part of the intestine. By this means, the essential enzymes for digestion are again kept in the small intestine.^

How does Roux-en-Y gastric bypass take effect and how does diabetes heal?

Gastric bypass shows both stomach volume-reducing and absorption-reducing effects. A stomach pouch of approximately 50 cc gets tight with a small amount of food and is felt to be full. In addition, since the first portion of the small intestine is closed to the food passage, the energy intake from the food is restricted.

In addition to these two effects, blocking the food contact with the first portion of the small intestine, such as in gastric bypass and duodenal switch, causes some hormonal changes. The small intestine is the largest hormone-releasing organ of the body except for food absorption function.

These hormones are called integrins. Peptide YY and GLP-1 appear to be the two most important hormones in the metabolism. The food bypassing the first portion of the small intestine and reaching further portions earlier increases the release of a hormone, called GLP-1.

The increased levels of GLP-1 break the insulin resistance in the tissues and leads to a rapid improvement in diabetes. Normal glucose levels of diabetic patients before weight loss in the postoperative early period is explained by the hormonal effect.

GLP-1 is the active ingredient of some diabetes drugs, but the hormone taken orally in the form of drug does not affect as much as usual response in the body. Insulin resistance is reduced by weight loss and reduced amount of fat in the tissues.

Sketchily, the work done by 100 units of insulin hormone begins to be done by 10 units of insulin. In addition to that, the hormone, called resistin, reaches higher levels and increases the insulin resistance in the tissues in patients with too much intra-abdominal fat. Decreased abdominal fat and lower resistin levels are other hormonal effects that break the insulin resistance.^

Advantages and disadvantages of Roux-en-Y gastric bypass surgery;

The greatest advantage of gastric bypass surgery is that it is a surgery that has been performed approximately for 60 years, and that all of the long-term results are well known. It both reduces the volume of the stomach and leads to a relatively low absorption impairment, causing weight loss.

It provides a faster recovery than sleeve gastrectomy surgery in morbidly obese patients with diabetes. On the other hand, vitamin and mineral deficiencies are more common than sleeve gastrectomy since the normal pathway of digestive tract is changed.

In the event of gaining weight again, it is technically more difficult to be revised and should be performed by very experienced teams.

One of the most important differences of gastric bypass from sleeve gastrectomy is that the stomach cut is removed in sleeve gastrectomy whereas it is left inside in gastric bypass. This means that a stomach with an invisible interior part remains in the body after gastric bypass surgery.^

What are the risks of Roux-en-Y gastric bypass surgery?

Apart from common risks of all other obesity operations, there are some procedure-specific risks. Stricture in the anastomosis area (anastomotic stricture) where the stomach pouches and the small intestine are tied, leakage in anastomosis, vitamins/mineral deficiencies are the most obvious risks of the procedure.

A condition called Dumping syndrome that is seen in all gastric surgeries in which the lower valve of the stomach (pylorus) is bypassed may occur after the surgery.

Sketchily, a fluid migration occurs from the body to inside of small intestine since foods taken uncontrollably pass through the small intestine due to bypassed natural valve in the output of the stomach, leading to complaints such as sweating, hypotension, blackout.

These complaints, which may usually occur after carbohydrate intake, are improved by regulating patient’s diet. The procedure-related mortality risk is around 0.4%.

The risk of gaining weight after the surgery is 15-16%. With the latest technological developments in the world of medicine, these surgeries are safely performed in experienced centres.^

Postoperative period of roux-en-Y gastric bypass surgery

On the postoperative next day, liquid foods are started and patients are discharged approximately within 3-4 days. After 1 week the patient returns to normal life. The expected weight loss at the end of one and a half years is 65-70% of the excess weight.