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


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

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[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