Roux-en-Y gastric bypass

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

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.

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
• 25% of patients require revision of their procedures after 10 years of follow-up

Procedure variants

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