Laparoscopic Gastric Bypass
Gastric bypass surgery (the Roux-en-Y gastric bypass) is usually performed under general anaesthesia using keyhole (laparoscopic) surgery. Small incisions are created in the abdominal wall to allow small instruments to be passed into the abdominal cavity, guided by a special surgical telescope with a video camera, in order to perform the operation.
Using surgical staples the surgeon will create a small pouch from the upper stomach, partitioning it from the lower part of your stomach. The stomach pouch is then connected directly to the middle portion of the small intestine (jejunum), bypassing the rest of the stomach and the upper portion of the small intestine (duodenum). Very rarely a drain is inserted to stop fluid from collecting inside your abdomen.
Professor Ammori also has expertise with the mini-gastric bypass operation in which the intestine is not divided but is linked to the small gastric pouch where 150-200cm of the jejunum is bypassed. This procedure is simpler than the Roux-en-Y gastric bypass and therefore might have lower complication rate, but offers weight loss comparable to the Roux-en-Y gastric bypass. However, there is a small risk of troublesome bile reflux that could be difficult to treat and might require laparoscopic conversion to Roux-en-Y gastric bypass in approximately 1% of patients.
In addition to reducing the capacity of the stomach, which restricts the amount you can eat and reduces your appetite, gastric bypass surgery reduces calorie absorption as food bypasses the rest of the stomach and the upper part of the small intestine. It also causes dumping syndrome (feeling dizzy and lightheaded if you eat too much carbohydrates or sweets due to food high in sugar passes quickly from the stomach pouch into the remaining small intestine) that will deter from food overindulgence.
In Professor Ammori’s hands, the average operating time for gastric bypass is 70 minutes in women and 90 minutes in men.
Most patients will be able to go home the following evening after surgery, and some 20% will stay an additional night or perhaps two depending on their health issues, especially their mobility, and availability of support at home.
Gastric bypass surgery is indicated for the following groups of people:
- When appropriate non-surgical measures have been tried but failed to achieve or maintain adequate, clinically beneficial weight loss in patients whose:
BMI is 40 kg/m2 or more
Or between 35-40 kg/m2 in association with other significant disease (for example, type 2 diabetes, heart disease or high blood pressure)
- It is also recommended as a first-line option (instead of lifestyle interventions or drug treatment) for adults with a BMI of more than 50 kg/m2 in whom surgical intervention is considered appropriate (National Institute for Clinical Excellence (NICE)).
- In March 2011, The International Diabetes Federation (IDF) recommended bariatric surgery to patients with BMI 30 kg/m2 (Asians from BMI 27.5 kg/m2) if their diabetes was poorly controlled.
- Gastric Bypass operation is particularly useful for those who crave for sweets (sweet-eaters)
However, the need for surgery to aid weight loss and the choice of surgical procedure is dependent on discussion with the bariatric team who will provide you expert and comprehensive advice.
- Considerable and durable weight loss up to 65-75% of excess body weight within 12-18 months.
- Marked improvement or resolution in health conditions related to obesity, particularly type-2 diabetes (approximately 80-85% chance of resolution), hypertension (60-75% chance of resolution) gastro-oesophageal reflux, obstructive sleep apnoea (90% chance of resolution), asthma, polycystic ovary syndrome (PCOS) and associated infertility, liver disease, high cholesterol, and painful osteoarthritis.
- Improvement in overall physical and psychological health
As with any surgical operations there are associated short and long-term complications such as internal bleeding, anastomosis Leakage, blood clot in the legs (deep vein thrombosis; DVT), blood clot in the lung (pulmonary embolism), infection, malabsorption of vitamins and micronutrients (which may lead to anaemia, weakness, osteoporosis and neurological problems), internal bowel hernia (less than 1%), ulcer perforation (0.8%), and weight regain.
However, Professor Ammori has performed over 2000 gastric bypass procedures with results that are amongst the best when compared to the World’s experience.
- In particular, he has not needed to convert any to an open operation.
- His procedure-related risk to life was 1-in-550 (0.15%) compared to a World average of 1-in-100 (1%).
- His anastomosis leak rate is 1-in-400 (0.25%) compared with a World average of 1-in-200 (0.5%). The joint between the stomach and intestine is hand-sewn to reduce the risk of leak and is then tested at the end of surgery with a blue dye to ensure “no leak” but until that joint heals (takes usually 2-3 weeks), you’ve got to stay on liquid diet and take acid-lowering tablets to prevent an ulcer at that joint.
- To prevent clots in the legs, we advise that you keep the elastic stockings we give you and to take the heparin injections for few days (occasionally for up to 4 weeks) after leaving the hospital. This is why perhaps only three patients in our experience have had clots after surgery.
- It is also essential to take the recommended iron-calcium and supplements multivitamin (including vitamin D and 3-monthly injections of vitamin B12) long-term and to have blood tests every year to check on these; otherwise there is a risk of vitamin and mineral deficiencies with their risks to health such as anaemia, excess hair loss, and rarely neurological complications.
- Professor Ammori routinely closes the mesenteric defects created when a gastric bypass is constructed in order to reduce the risk of future internal small bowel herniation and bowel obstruction. However, that risk cannot be eliminated completely (approximately 0.5% in Professor Ammori’s experience).
- Approximately 1:120 patients (0.8%) will develop an ulcer at the anastomosis between the stomach pouch and intestine (called “marginal ulcer”). rarely, an ulcer may bleed or perforate with associated risk to life. It is essential that bypass patients should not smoke after surgery as this is the most important risk factor for developing a marginal ulcer. Professor Ammori recommends that one should take an anti-ulcer therapy for 2 years after surgery and should avoid NSAID type drugs (such as brufen, ibuprofen or voltarol) whenever possible. He routinely takes a biopsy from the stomach pouch at the time of construction of a gastric bypass in order to detect a bug in the stomach that is sometimes present, called H. pylori, that could cause ulcers, and to eradicate it with a course of antibiotics. Rarely a marginal ulcer may result in a narrowing at the anastomosis (called “stricture”), and this could be managed by a gastroscopy and balloon dilatation, but rarely might require a laparoscopic refashioning of the anastomosis. In the very rare situation of a persistent or recurring marginal ulcer, one might have to consider laparoscopic reversal of the gastric bypass and possibly a conversion to a sleeve gastrectomy.
- Malnutrition after a gastric bypass (the standard is a “proximal” rather than distal gastric bypass) is quite rare, but might require nutritional support and possibly laparoscopic reversal of the gastric bypass. Excess alcohol intake is a risk factor for protein malnutrition and should be avoided. This is particularly relevant as there is some evidence that some patients after a gastric bypass take to drinking alcohol in excess.
- Bacterial overgrowth in the bypassed segment of small intestine is also rare and results in diarrhoea. There are other causes for diarrhoea after a gastric bypass such as excess fat and sugar intake. Bacterial overgrowth is usually easily managed by a course of antibiotics.
Professor Basil Ammori ( based in Manchester, UK) always gives his personal number to all his private patients (this is in addition to the contact numbers of the bariatric nurse, dietitian and the ward) so that they might reach him without delay in case of emergency.