Difference between revisions of "Roux-en-Y gastric bypass"
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A procedural variant for gastric partitioning for morbid obesity where the stomach is partitioned into a proximal and distal pouch with an anastomosis to the jejunum to drain the proximal pouch. | A procedural variant for gastric partitioning for morbid obesity to reduce food intake where the stomach is partitioned into a proximal and distal pouch (<50mL) with an anastomosis to the jejunum to drain the proximal pouch<ref>{{Cite journal|last=Heymsfield|first=Steven B.|last2=Wadden|first2=Thomas A.|date=2017-04-13|title=Mechanisms, Pathophysiology, and Management of Obesity|url=https://pubmed.ncbi.nlm.nih.gov/28402780|journal=The New England Journal of Medicine|volume=376|issue=15|pages=1492|doi=10.1056/NEJMc1701944|issn=1533-4406|pmid=28402780}}</ref>. Food then bypasses over 95% of the stomach, duodenum, and jejunum. Many patients who have Roux-en-Y gastric bypass lose more than 25% of weight after 1 year<ref>{{Cite journal|last=Ikramuddin|first=Sayeed|last2=Korner|first2=Judith|last3=Lee|first3=Wei-Jei|last4=Connett|first4=John E.|last5=Inabnet|first5=William B.|last6=Billington|first6=Charles J.|last7=Thomas|first7=Avis J.|last8=Leslie|first8=Daniel B.|last9=Chong|first9=Keong|last10=Jeffery|first10=Robert W.|last11=Ahmed|first11=Leaque|date=2013-06-05|title=Roux-en-Y gastric bypass vs intensive medical management for the control of type 2 diabetes, hypertension, and hyperlipidemia: the Diabetes Surgery Study randomized clinical trial|url=https://pubmed.ncbi.nlm.nih.gov/23736733|journal=JAMA|volume=309|issue=21|pages=2240–2249|doi=10.1001/jama.2013.5835|issn=1538-3598|pmc=3954742|pmid=23736733}}</ref>. | ||
==Preoperative management== | ==Preoperative management== | ||
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*Aspiration | *Aspiration | ||
*Backwall suture of anastamosis | *Backwall suture of anastamosis | ||
*Mortality is 0.2-0.3% with a laparoscopic approach<ref>{{Citation|last=O'Brien|first=Paul|title=Surgical Treatment of Obesity|date=2000|url=http://www.ncbi.nlm.nih.gov/books/NBK279090/|work=Endotext|editor-last=Feingold|editor-first=Kenneth R.|place=South Dartmouth (MA)|publisher=MDText.com, Inc.|pmid=25905316|access-date=2021-06-05|editor2-last=Anawalt|editor2-first=Bradley|editor3-last=Boyce|editor3-first=Alison|editor4-last=Chrousos|editor4-first=George}}</ref> | |||
*25% of patients require revision of their procedures after 10 years of follow-up<ref>{{Citation|last=O'Brien|first=Paul|title=Surgical Treatment of Obesity|date=2000|url=http://www.ncbi.nlm.nih.gov/books/NBK279090/|work=Endotext|editor-last=Feingold|editor-first=Kenneth R.|place=South Dartmouth (MA)|publisher=MDText.com, Inc.|pmid=25905316|access-date=2021-06-05|editor2-last=Anawalt|editor2-first=Bradley|editor3-last=Boyce|editor3-first=Alison|editor4-last=Chrousos|editor4-first=George}}</ref> | |||
==Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). -->== | ==Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). -->== | ||
Revision as of 09:43, 5 June 2021
Roux-en-Y gastric bypass
| Anesthesia type |
General |
|---|---|
| Airway |
ETT |
| Lines and access |
PIV OG tube |
| Monitors |
Standard, nasal temp |
| Primary anesthetic considerations | |
| Preoperative |
Potential difficult ventilation and airway management |
| Intraoperative |
Rapid sequence, ramped position |
| Postoperative |
PONV, IV tylenol |
| Article quality | |
| Editor rating | |
| User likes | 0 |
A procedural variant for gastric partitioning for morbid obesity to reduce food intake where the stomach is partitioned into a proximal and distal pouch (<50mL) with an anastomosis to the jejunum to drain the proximal pouch[1]. Food then bypasses over 95% of the stomach, duodenum, and jejunum. Many patients who have Roux-en-Y gastric bypass lose more than 25% of weight after 1 year[2].
Preoperative management
Patient evaluation
| System | Considerations |
|---|---|
| Neurologic | |
| Cardiovascular | Evaluate for hypertension
OSA causing pulmonary arterial hypertension |
| Respiratory | Evaluate BMI for decreased FRC
Evaluate OSA status for difficult mask ventilation |
| Gastrointestinal | Consider delayed gastric emptying with diabetes mellitus |
| Hematologic | |
| Renal | |
| Endocrine | Consider delayed gastric emptying with diabetes mellitus |
| Other |
Labs and studies
- Sleep study (AHI score if available) for OSA
Operating room setup
- Consider ramp for airway management
- Consider video laryngoscopy
- OG tube
- Methylene Blue and 60mL syringe
Patient preparation and premedication
- Minimize perioperative sedation
Regional and neuraxial techniques
- Consider post-operative TAP block
Intraoperative management
Monitoring and access
- Standard ASA monitors
Induction and airway management
- Consider rapid sequence induction
- Video laryngoscopy can be helpful for anticipated difficult airways
Positioning
- Supine
- Extreme reverse Trendelenburg (place baseboard by feet)
Maintenance and surgical considerations
- OG tube is advanced through the surgical anastomosis to prevent backwall suturing of anastomosis
- Surgical and anesthesia communication and coordination is important to guide OGT through anastomosis
- Methylene blue 60mL used at the end of the case to pressurize the proximal pouch and look for leaks across the staple line of the anastomosis.
Emergence
Postoperative management
Disposition
- PACU
Pain management
- Moderate pain: IV and oral narcotics
Potential complications
- Bleeding
- Thromboemobolic events
- Aspiration
- Backwall suture of anastamosis
- Mortality is 0.2-0.3% with a laparoscopic approach[3]
- 25% of patients require revision of their procedures after 10 years of follow-up[4]
Procedure variants
| Variant 1 | Variant 2 | |
|---|---|---|
| Unique considerations | ||
| Position | ||
| Surgical time | ||
| EBL | ||
| Postoperative disposition | ||
| Pain management | ||
| Potential complications |
References
- ↑ Heymsfield, Steven B.; Wadden, Thomas A. (2017-04-13). "Mechanisms, Pathophysiology, and Management of Obesity". The New England Journal of Medicine. 376 (15): 1492. doi:10.1056/NEJMc1701944. ISSN 1533-4406. PMID 28402780.
- ↑ Ikramuddin, Sayeed; Korner, Judith; Lee, Wei-Jei; Connett, John E.; Inabnet, William B.; Billington, Charles J.; Thomas, Avis J.; Leslie, Daniel B.; Chong, Keong; Jeffery, Robert W.; Ahmed, Leaque (2013-06-05). "Roux-en-Y gastric bypass vs intensive medical management for the control of type 2 diabetes, hypertension, and hyperlipidemia: the Diabetes Surgery Study randomized clinical trial". JAMA. 309 (21): 2240–2249. doi:10.1001/jama.2013.5835. ISSN 1538-3598. PMC 3954742. PMID 23736733.
- ↑ O'Brien, Paul (2000), Feingold, Kenneth R.; Anawalt, Bradley; Boyce, Alison; Chrousos, George (eds.), "Surgical Treatment of Obesity", Endotext, South Dartmouth (MA): MDText.com, Inc., PMID 25905316, retrieved 2021-06-05
- ↑ O'Brien, Paul (2000), Feingold, Kenneth R.; Anawalt, Bradley; Boyce, Alison; Chrousos, George (eds.), "Surgical Treatment of Obesity", Endotext, South Dartmouth (MA): MDText.com, Inc., PMID 25905316, retrieved 2021-06-05
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