Roux en Y Gastric Bypass - RNY or Runy

Roux-en-Y Gastric Bypass (RNY):

There are a number of techniques currently in use for the surgical treatment of morbid obesity. The one currently favored by the New York Bariatrics Surgery team is the Roux-en-Y gastric bypass. This is the most commonly performed weight loss surgery procedure in the United States, being performed about 75% of the time.

This surgery involves creating a small (less than one ounce) vertically oriented stomach pouch, as well as a bypass of most of the stomach and a varying amount of small intestine (see figure). As a result, weight loss is accomplished both by restriction of food and by malabsorption of nutrients. Ingestion of concentrated sugar is also essentially prohibited because doing so results in "dumping." Dumping is a group of unpleasant symptoms that resembles food poisoning (nausea, vomiting, diarrhea, abdominal cramps, flushing, and palpitations) that occurs when simple sugars enter the small intestine without first being properly digested by the stomach. Many people also report diminished appetite after Roux-en-Y gastric bypass, as well as a change in the taste of food. By looking at the diagram of the Roux en Y gastric bypass it may seem intuitive that this configuration interferes with the normal digestion of food. This is so because the digestive enzymes normally produced in the stomach and upper small intestine continue to be made, but do not contact the food that has been ingested until a few feet down the intestine. Hence, the digestion of the food is delayed until it is already part way down the intestine.” These are additional ways the gastric bypass causes weight loss. Following RNY surgery, patients are at risk for developing anemia because of poor absorption of iron and vitamin B12. Therefore, dietary supplementation of these nutrients is required. Poor absorption of calcium may also occur. Thus, calcium supplements must also be taken postoperatively.

Since the staples at the top of the stomach completely block off the lower portion of the stomach and the upper small intestine, there is no easy way to evaluate these portions of the gastrointestinal tract should a problem -- such as ulcer, bile duct stones, or cancer -- arise at a future time. In fact, although this could be a very real problem, it seldom becomes as issue.

Weight loss commonly reaches 75% of a person's excess body weight. As in all weight loss surgery, however, the amount of weight loss is not guaranteed. In fact, there is no guarantee that the patient will lose any weight at all. The amount of weight a patient loses depends not only upon the surgery, but also upon what the patient does with the surgery. The surgery is not a cure for morbid obesity; it is merely a tool. Patients have been known to ingest large quantities of high caloric foods that can result in less than satisfactory weight loss. If a patient adheres to the dietary booklet that she or he receives as part of the New York Bariatrics Program, and if exercise becomes a part of the patient's regular routine, a substantial weight loss usually results. The Roux-en-Y gastric bypass routinely necessitates a stay of three or four days in the hospital.

As in any sort of major surgery, there is a certain amount of risk. It is important to consider these risks when deciding to have weight loss surgery. Operative risks are: death (0.5%), leaks or perforation causing internal infection and need for reoperation (0.6%), wound infection (2 %), and pulmonary embolism (0.1%).

Technical aspects of the RNY gastric bypass procedure

The New York Bariatrics surgery program performs the RNY procedure using either the laparoscopic technique or the open (traditional) method.

Laparoscopic Roux-en-Y gastric bypass is identical to the traditional gastric bypass except that instead of being performed through an incision extending from the lowest aspect of the breastbone (xiphoid process) to the umbilicus (navel), it is performed through several smaller incisions each measuring about an inch or less in length. A laparoscope connected to a video camera is inserted into the abdominal cavity and the surgical field is visualized on video monitors in the operating room. Long thin surgical instruments are inserted through additional small incisions and the surgeon performs the surgery by watching the video monitor. The operation is performed in a virtually identical manner whether it is done laparoscopically or open.

The advantages to performing the gastric bypass laparoscopically are that it yields cosmetically superior results and the recovery is faster. Some long-term problems, such as incisional hernias, may also occur less frequently. One disadvantage of laparoscopy is that sometimes, because of difficulty in visualization, the operation must be converted to an open procedure in order to complete the operation safely. This decision frequently can only be made during the course of the operation while the patient is under anesthesia, so the patient must be aware of this possibility before the surgery starts. Another disadvantage is that the incidence of leakage from the surgical staple lines may be more common in the postoperative period. Leakage from the staple line is a serious complication and often necessitates additional surgery, usually using a traditional incision, and prolonged hospitalization, and sometimes even death.

Sometimes previous abdominal surgeries make doing the laparoscopic technique difficult or impossible, because of adhesions (scarring), so the open procedure is preferred in these patients. Similarly, revisions to previous failed weight loss surgery usually entail an open procedure. Patients whose BMI’s exceed 55 are also frequently better managed with the open, rather than the laparoscopic, technique to cut down on anesthesia time and to avoid complications that may occur because of limited exposure (visualization) that occurs with laparoscopy.

Results Substantial weigh loss occurs in the great majority of patients after Roux-en-Y gastric bypass (RNY). Weight loss results are the same whether the surgery is performed laparoscopically or open. The vast majority of patients are satisfied or very satisfied with the results of the surgery. Losing about 50% of one's excess weight is considered a satisfactory weight loss, although weight loss after RNY frequently approximates 75% of excess weight. After losing this amount of weight, patients usually feel physically and mentally better. Preoperative comorbidities such as diabetes, hypertension, stress incontinence, back pain, knee pain, heel spurs, sleep apnea and other complications of obesity are usually either improved or eliminated altogether.

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