Difference between revisions of "Roux-en-Y gastric bypass"
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| lines_access = PIV | | lines_access = PIV | ||
OG tube | OG tube | ||
| monitors = Standard | | monitors = Standard | ||
Temperature (not esophageal) | |||
| considerations_preoperative = Potential difficult ventilation and airway management | | considerations_preoperative = Potential difficult ventilation and airway management | ||
| considerations_intraoperative = Rapid sequence, ramped position | | considerations_intraoperative = Rapid sequence, ramped position | ||
| considerations_postoperative = PONV | | considerations_postoperative = PONV | ||
IV acetaminophen | |||
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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>. | 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== | ==Preoperative management== | ||
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OSA causing pulmonary arterial hypertension | OSA causing pulmonary arterial hypertension | ||
|- | |- | ||
| | |Pulmonary | ||
|Evaluate BMI for decreased FRC | |Evaluate BMI for decreased FRC | ||
| Line 104: | Line 106: | ||
*Bleeding | *Bleeding | ||
* | *Thromboembolic events | ||
*Aspiration | *Aspiration | ||
*Backwall suture of | *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> | *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> | *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> | ||
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[[Category:Surgical procedures]] | [[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 | |
| 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
- ↑ 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.
- ↑ 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)
- ↑ 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
Top contributors: Jessica Leung, Nirav Kamdar and Chris Rishel