Gastric Bypass Surgery- Video 11

Gastric Bypass Surgery- Video 11


(calm music snippet) – I’d like to review with
you today just some of the more important issues dealing
with a very popular operation known as the laparoscopic
roux-en-y gastric bypass. We ut that term, laparoscopic,
on the front of that discussion because it’s
been the most popular way to perform this procedure
over the last 10 years in our practice, and in almost 15 years in other parts of the world. But this kind of an operation is designed to help people lose significant weight. In fact, some studies have
shown that, in the long term, when we’re talking about 14 to
15 years, the average patient will lose perhaps 50 or
60% of excess body weight and keep that weight off
over those many years. Very importantly too, these
patients can experience a significant improvement
in co-morbid conditions, and by that, we mean disease
processes such as hypertension, diabetes, high cholesterol,
high triglycerides, heart failure, and severe
obstructive sleep apnea, to mention a few of the
more common problems. Just to review the anatomy
of what’s happening here, we’ve created a small
stomach, which will restrict how much a person can
eat during a meal time. We try to make that as
small as two ounces per meal in the first phase of the
operation, and then maybe never let a person eat more than
eight ounces in a meal long-term, as they adapt to it. The small valves connected
to this little stomach in what’s called an anastomosis. The term for that, more specifically, is the gastrojejunostomy. And in our practice, we
hand sew this, we have it at fixed size, it’s about the
size of an index finger, for my index finger size,
and it helps restrict the flow of food, but it
does bring the food back down to the digestive enzyme
stream, which is coming from the duodenum, where the
pancreas and the bile from the liver flow in,
and then they join together in a connection here again. This, if you look at it closely,
is another connection or anastomosis, and this one is
called the jejunojejunostomy, because we’re connecting
jejunum to jejunum. And after that point, we have
what’s called the common limb, and in actual fact, this
picture doesn’t tell the true story, it’s about three
fourths of the bowel length or about 10 or more feet of small bowel from here to the large bowel. So by the time this food
stream has joined with the enzyme stream, we
have normal digestion. And so we rarely see
patients get in trouble with too low of a albumin or too
low of a nutritional level, as long as they eat reasonable
and much smaller amounts of food for the rest of the
lives and take their vitamins, they will do quite nicely. So what happens with a
bypass is we now know that one of the more
potent hunger stimulants, a hormone known as ghrelin,
it’s smelled G-H-R-E-L-I-N, is normally released in
greater amounts when you fast or restrict caloric
intake, unless you’ve had a gastric bypass, in which
case, the food stream goes around the stomach and the duodenum, and as a consequence, that
hormone is no longer released, which is very nice for
patients who are trying to lose weight, to have
that appetite stimulant be taken out of their
system and allow them to have greater control
of weight as a result. Some of the reasons that
patients might have some fears about this is because it is major surgery, we are altering Mother
Nature to try to get a gain that wasn’t realized just
through self discipline alone. So there are some disadvantages
to doing this surgery. The nice thing is that
it’s a very safe kind of operative procedure to
perform when compared to other commonly-performed major
abdominal surgeries, such as hysterectomies,
or total knee prostheses, or any heart surgery. The risk of an adverse
event or life-threatening complication is much much lower. But it’s not zero, and as a
result, some people will have serious complications,
and we have to take those into consideration. Other things that have to
be addressed are the fact that you do have some
degree of malabsorption, and you will have to
take vitamin supplements, particularly vitamin B12,
a common multivitamin in addition to that, and
then calcium supplements. In any case, those numbers
need to be measured, vitamin D levels, calcium
levels, folate, B12, thiamine, every year to make sure
that everything is okay with vitamin levels. There is another issue,
called dumping syndrome. When you pour food straight
from your esophagus through a little stomach
and into small bowel, triggering the release of
some hormones that normally wouldn’t have been released,
because the food would have been processed going through
the lower stomach and duodenum. In any case, these hormones
can have a very active effect on your whole body, which
then lead to what’s called a dumping syndrome, the bowel
quickens in its irritability, the peristaltic rate goes up, the body can release enzymes
and hormones which will make your heart quicken, you
might even perspire, you could have some abdominal
rumbling and grumbling, and that’s known as the dumping syndrome. It isn’t diarrhea, per se,
that’s an issue that doesn’t necessarily go along with
that syndrome, but can. It’s precipitated by anybody
who eats too much rich food too fast, especially after
they have this new anatomy, so it’s a matter of
counseling and guidance to avoid that particular problem. This operation is a little bit difficult to put back to normal. You’d have to undo this
connection and this one, reconnect stomach to itself
and this small bowel to here, and we rarely would ever want to do that, but if that should come up,
it is possible to be done. We keep these patients in
the hospital for one night. In most cases, 95% of the
time, they’re discharged on the next post-operative
day, we like to observe them perhaps longer than we would with a band, because it’s a more complex operation. Complications can occur
with this operation as well that have to do with the mechanics of the surgical procedure itself. We can develop a tightening
in this connection here, known as a stricture, which
might require dilation. Usually that’s an outpatient
procedure done with an endoscope, doesn’t
require another operation, but that sometimes shows up, perhaps, one in every 20 patients or so. Early on in the surgery,
we can see a little leakage of intestinal content
through either a staple line or a suture line. That’s one of the vagaries of
doing this kind of surgery, we’d like to test our
connections and our seals under the operative
circumstances when we’re in the operating room, to
make sure we’re not leaving an obvious problem behind, and
that reduces our leak rate, if we want to call it down,
down to well less than 1%. Sometimes, because the bowel
has been rearranged, as it has, they can develop a bowel obstruction, and that can happen after
any abdominal surgery. Scar tissue can form, the
bowel can twist or kink, and so, we have to be aware,
as patients, you need to be aware that if you’re having
pain that doesn’t seem right, and especially if it’s severe,
you need to be contacting me or one of my colleagues
or whoever was your surgeon right away to be sure that
isn’t a serious issue. We think that the mortality
rate on this operation in our practice is better than
what is reported nationally. Our statistics suggest it’s
about a 1/10th of 1% mortality at 30 days, which means
one in a thousand patients would be at risk of death. Nationally, it’s probably 2/10ths of 1%, or two out of a thousand. In any case, if we can get to patients, should they have leaks, or
if they develop a blood clot early on in their recovery,
we will have a better chance of rescuing them and preventing this from becoming something serious. If you don’t take your
vitamins, you run the risk of developing neuropathy, which
means that either the brain or the peripheral nervous
system doesn’t work properly, you can see this with
vitamin B12 deficiency, with acute thiamine deficiency. So this has to be safeguarded
in terms of taking your vitamins daily in order
to prevent these problems, and if you’re having trouble
ingesting your vitamins, then you get immediately
in with your physician who did your surgery. I think that pretty much
wraps up the good things and the bad things about this operation. Overall, I think the
message should be that it’s a very healthy, wonderful
opportunity to help us deal with a problem that
heretofore hasn’t had a really great solution,
and you’ll be hearing more about some other options,
which also have admirable track records, and so I’ll
defer to my colleagues to discuss that as we
continue this little lesson. (calm music snippet)

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