Difference between revisions of "Roux-en-Y gastric bypass"

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{{Infobox surgical case reference
| anesthesia_type = General
| airway = ETT
| lines_access = PIV
OG tube
| monitors = Standard
Temperature (not esophageal)
| considerations_preoperative = Potential difficult ventilation and airway management
| considerations_intraoperative = Rapid sequence, ramped position
| considerations_postoperative = PONV
IV acetaminophen
}}


A '''Roux-en-Y gastric bypass''' is 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>. Patients who had Roux-en-Y gastric bypass experienced higher remission and lower rates of hypertension, diabetes, and hyperlipidemia<ref>{{Cite journal|last=Adams|first=Ted D.|last2=Davidson|first2=Lance E.|last3=Litwin|first3=Sheldon E.|last4=Kim|first4=Jaewhan|last5=Kolotkin|first5=Ronette L.|last6=Nanjee|first6=M. Nazeem|last7=Gutierrez|first7=Jonathan M.|last8=Frogley|first8=Sara J.|last9=Ibele|first9=Anna R.|last10=Brinton|first10=Eliot A.|last11=Hopkins|first11=Paul N.|date=2017-09-21|title=Weight and Metabolic Outcomes 12 Years after Gastric Bypass|url=http://www.nejm.org/doi/10.1056/NEJMoa1700459|journal=New England Journal of Medicine|language=en|volume=377|issue=12|pages=1143–1155|doi=10.1056/NEJMoa1700459|issn=0028-4793|pmc=PMC5737957|pmid=28930514}}</ref>. 
==Preoperative management==
===Patient evaluation<!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. -->===
{| class="wikitable"
|+
!System
!Considerations
|-
|Neurologic
|
|-
|Cardiovascular
|Evaluate for hypertension
OSA causing pulmonary arterial hypertension
|-
|Pulmonary
|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<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. -->===
*Sleep study (AHI score if available) for OSA
===Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. -->===
*Consider ramp for airway management
*Consider video laryngoscopy
*OG tube
*Methylene Blue and 60mL syringe
===Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. -->===
*Minimize perioperative sedation
===Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. -->===
* Consider post-operative TAP block
==Intraoperative management==
===Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. -->===
*Standard ASA monitors
===Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. -->===
*Consider rapid sequence induction
*Video laryngoscopy can be helpful for anticipated difficult airways
===Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. -->===
*Supine
*Extreme reverse Trendelenburg (place baseboard by feet)
===Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. -->===
*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<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. -->===
==Postoperative management==
===Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. -->===
*PACU
===Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. -->===
*Moderate pain: IV and oral narcotics
===Potential complications<!-- List and/or describe any potential postoperative complications for this case. -->===
*Bleeding
*Thromboembolic events
*Aspiration
*Backwall suture of anastomosis
*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). -->==
{| class="wikitable"
|+
!
!Variant 1
!Variant 2
|-
|Unique considerations
|
|
|-
|Position
|
|
|-
|Surgical time
|
|
|-
|EBL
|
|
|-
|Postoperative disposition
|
|
|-
|Pain management
|
|
|-
|Potential complications
|
|
|}
==References==
[[Category:Surgical procedures]]
<references />
[[Category:General surgery]]
[[Category:Stomach surgery]]
[[Category:Bariatric surgery]]
[[Category:Gastric bypass surgery]]

Latest revision as of 23:15, 4 April 2022

Roux-en-Y gastric bypass
Anesthesia type

General

Airway

ETT

Lines and access

PIV OG tube

Monitors

Standard Temperature (not esophageal)

Primary anesthetic considerations
Preoperative

Potential difficult ventilation and airway management

Intraoperative

Rapid sequence, ramped position

Postoperative

PONV IV acetaminophen

Article quality
Editor rating
In development
User likes
0

A Roux-en-Y gastric bypass is 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]. Patients who had Roux-en-Y gastric bypass experienced higher remission and lower rates of hypertension, diabetes, and hyperlipidemia[3].

Preoperative management

Patient evaluation

System Considerations
Neurologic
Cardiovascular Evaluate for hypertension

OSA causing pulmonary arterial hypertension

Pulmonary 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
  • Thromboembolic events
  • Aspiration
  • Backwall suture of anastomosis
  • Mortality is 0.2-0.3% with a laparoscopic approach[4]
  • 25% of patients require revision of their procedures after 10 years of follow-up[5]

Procedure variants

Variant 1 Variant 2
Unique considerations
Position
Surgical time
EBL
Postoperative disposition
Pain management
Potential complications

References

  1. ↑ 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.
  2. ↑ 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.
  3. ↑ Adams, Ted D.; Davidson, Lance E.; Litwin, Sheldon E.; Kim, Jaewhan; Kolotkin, Ronette L.; Nanjee, M. Nazeem; Gutierrez, Jonathan M.; Frogley, Sara J.; Ibele, Anna R.; Brinton, Eliot A.; Hopkins, Paul N. (2017-09-21). "Weight and Metabolic Outcomes 12 Years after Gastric Bypass". New England Journal of Medicine. 377 (12): 1143–1155. doi:10.1056/NEJMoa1700459. ISSN 0028-4793. PMC 5737957. PMID 28930514.CS1 maint: PMC format (link)
  4. ↑ 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
  5. ↑ 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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