Anatomy - Laparoscopic gastric bypass - general and visceral surgery

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  • Universitäts Klinik Witten Herdecke

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  • Introduction

    The incidence and prevalence of morbid obesity with its associated comorbidities is increasing worldwide, particularly in Western countries. According to the WHO, 600 million people are obese (BMI > 30 kg/m2).

    As evidenced by high-quality data, bariatric and metabolic surgical procedures are the most effective and long-lasting treatment modalities in morbid obesity and outperform nonsurgical multimodal regimens.

    In addition to achieving sustained weight loss, surgery can also successfully treat obesity-related comorbidities, such as type 2 diabetes, arterial hypertension, lipid metabolic disorders, and sleep apnea syndrome.

    The proliferation and acceptance of bariatric surgery has increased significantly worldwide over the past 20 years (approx. 150,000 procedures in 2003; 470,000 in 2013).

    Successful bariatric surgery outcome is evaluated based on effective weight loss and a positive effect on associated morbidities.

    Roux-en-Y gastric bypass (RYGB) is the gold standard of bariatric surgery, accounting for about 45%.

    The large number of complex changes with metabolic effects unfolding in the enterohumoral axis because of surgery go well beyond weight loss.

    The new term “metabolic surgery” reflects the expanded indication. It is expected that bariatric surgery will play a greater role in the management of metabolic syndrome.

    Many patients with type 2 diabetes show complete remission within days of surgery and long before significant weight loss. The current discussion has evolved to the issue of treating normal weight and slightly overweight diabetics by metabolic surgery as well.

    With the advent of laparoscopic surgical techniques, these procedures, initially regarded as high-risk surgery, can now be effected with an acceptable risk profile.

    Bariatric and metabolic operations are not included in the Standard Benefits Catalog of the German Health Insurance providers. Therefore, each patient must apply individually to his/her provider for this type of surgery.

  • Physiological mechanisms of gastric bypass

    While restriction and malabsorption are prerequisites for successful treatment, hormonal and neural mechanisms appear to be the chief determinants in improving the diabetic metabolism.

    The complex interplay of hunger and satiety, as well as metabolism and energy balance, undergoes specific change as a result of this type of surgery.

    In addition to restriction and malabsorption, the postgastric bypass modified gastrointestinal anatomy induces manifold physiological changes, for example, in gastrointestinal hormone secretion, neuroendocrine signaling and the intestinal microbiome.

    Compared with purely restrictive procedures (gastric banding), following bypass surgery patients experience early satiety and reduced hunger. All procedures bypassing the gastric fundus as the main site of ghrelin production have a lasting impact on hunger suppression.

    Furthermore, bypassing the duodenal receptors and proximal jejunum from intestinal transit and rapidly transporting food to distal small bowel segments stimulates enterohormonal secretion and improves glucose metabolism.

    More than 80% of postsurgery patients can discontinue insulin treatment or oral medication.

  • Technique of Proximal Gastric Bypass (RYGBP)

    Paid content (image)

    In laparoscopic Roux-en-Y gastric bypass a small gastric pouch (20-30 ml) is first fashioned  by dividing the subcardiac stomach with staplers from the rest of the stomach. The division must be total with no tissue bridge to the rest of the stomach.

    Then the fashioned gastric pouch is anastomosed with the Roux-en-Y jejunal limb. Thus, food transit will bypass the duodenum and part of the jejunum. The brought-up Roux limb is known as the “alimentary or efferent limb” and is anastomosed with the “biliopancreatic or afferent limb” 150 cm distal to the enteroenterostomy. Following the anastomosis of these two limbs, the actual absorption of food takes place in the “common channel”.