Roux en-Y gastric bypass (RYGB) has long been considered the “gold standard” bariatric operation because it is the only procedure that has withstood the test of time. Although gastric bypass was first performed in the 1960’s, it did not become popular until the introduction of minimally invasive / laparoscopic techniques in the late 1990’s.
Although riskier than sleeve gastrectomy and laparoscopic banding, the short and long term risks are considered acceptable in the context of superior weight loss and improvement of medical comorbidities in comparison with those two procedures.
Complications of Gastric Bypass
Complications of gastric bypass are similar to those associated with other gastric bariatric operations.
LEAK – This is the most feared early complication. The great majority of leaks after RYGB occur within the first week postoperatively. Early recognition of leaks usually results in successful treatment. Mortality, disability and prolonged hospitalization are typically associated with delayed diagnosis. Leaks after RYGB usually heal more quickly than those associated with sleeve gastrectomy.
DEEP VENOUS THROMBOSIS / PULMONARY EMBOLISM – Blood clots, pulmonary embolism (PE) and Deep Venous Thrombosis (DVT) are relatively uncommon after laparoscopic RYGB. PE occurs suddenly and may be fatal if massive. DVT not associated with PE is rare. Current methods of DVT prophylaxis have substantially reduced the incidence of this complication during the past two decades.
INTESTINAL OBSTRUCTION / BLOCKAGE – The late complications associated with gastric bypass are generally related to the rearrangement of gastrointestinal anatomy inherent in the procedure. Intestinal obstruction (blockage) is a lifetime risk of RYGB. Most cases occur within the first three years postoperatively. Symptoms tend to progress rapidly and consist of nausea, abdominal cramps, vomiting and cessation of passing gas and bowel movements. This constellation of symptoms should prompt any RYGB patient to call their bariatric surgeon (far preferable versus their primary MD) who should direct them to an appropriate emergency room for evaluation.
Many cases of obstruction that develop after laparoscopic RYBG are associated with herniation / twisting of the intestine, which is potentially life-threatening. Herniated intestinal obstruction is difficult to diagnose with x-rays or CT scanning. For these reasons, urgent / emergent surgery is usually performed. Early surgical treatment of obstruction usually results in prompt and full recovery.
MARGINAL ULCER – This is a type of ulcer that develops where the jejunum is attached to the gastric pouch. The jejunum / small intestine is very sensitive to gastric acid. Although the pouch in RYGB typically produces very little acid, in some patients the quantity is sufficient to cause a marginal ulcer. Patients with marginal ulcers often present with upper abdominal pain and/or progressive intolerance of solid food. Others present with painless rectal bleeding characterized by voluminous maroon colored stool and/or vomiting bright red blood. Ulcers related to bleeding usually require hospitalization and occasionally urgent revisional surgery.
Most marginal ulcer patients with bleeding can be stabilized and do not require urgent surgery. Most patients who develop marginal ulcers are successfully treated with anti-ulcer medication. A substantial percentage of patients have anatomic abnormalities that potentiate development of ulcers, such as an enlarged gastric pouch or an abnormal connection / fistula between the pouch and the formerly excluded / bypassed stomach.
Surgical treatment is often required for marginal ulcers that are associated with anatomic abnormalities. These operations usually reduce the size of the pouch and redo the connection / anastomosis between the pouch and jejunum. Because these are revisional operations, the associated risks are considerably higher in comparison with the primary (first time) operations. Reversal rather than revision is occasionally recommended to smokers with ulcers who refuse to stop smoking and to patients who require large doses of a variety of pain medications for various maladies.
HERNIA – Hernia in an incision is a relatively uncommon complication of laparoscopic RYGB. Conversely, a substantial number of patients who had open RYGB developed incisional hernias. These hernias typically cause pain in the area of the incision and occasionally intestinal obstruction. Most patients with symptomatic hernias require operation.
VITAMIN / MINERAL DEFICIENCY – Because rearrangement of normal gastrointestinal anatomy is inherent in RYGB, absorption of some dietary nutrients is compromised. RYGB is associated with a variety of vitamin and mineral deficiencies, most notably iron, vitamin B-12 and calcium.
IRON DEFINICIENCY – This is the most common and may be particularly troublesome in menstruating women. Oral iron supplements are occasionally inadequate to correct and control iron deficiency and associated anemia. Intravenous iron infusion is frequently required in patients who don’t respond to oral iron. Hysterectomy is effective in women who do not want more children. Menopause often results in dramatic improvement.
VITAMIN B-12 DEFICIENCY – This is fairly common after RYGB in patients who do not regularly take their multivitamin supplements. Symptoms and/or anemia caused by B-12 deficiency are rare. Frequently resumption of oral multivitamins will correct B-12 deficiency. Occasionally additional B-12 is required.
THIAMIN / VITAMIN B1 DEFICIENCY – This is a rare but potentially serious problem that has been reported after several types of gastric bariatric operations, including RYGB. Thiamin deficiency typically develops within the first few weeks after RYGB and is almost invariably associated with severe vomiting after eating and drinking. Patients who cannot consistently keep liquids and oral vitamin supplements down should contact their surgeon and be prepared for immediate hospitalization.
Symptoms and signs of thiamin deficiency generally develop within a few days to several weeks after the onset of severe vomiting. Early symptoms are subtle and include numbness and tingling in the hands, arms and lower legs, accompanied by problems maintaining balance. Without treatment, symptoms can progress to mental confusion, weakness and difficulty walking, ultimately resulting in paralysis of the same muscle groups, coma and death. Some of these symptoms may persist even after treatment.
The best treatment of thiamin deficiency is prevention. Hospitalization of patients with severe vomiting along with administration of thiamin by injection usually prevents development of symptoms. Likewise, early symptoms tend to respond to thiamin injections. Conversely, delayed treatment allowing for development of more severe signs and symptoms can result in permanent disability.
DUMPING – This is a condition that occurs commonly after RYGB. The symptoms of dumping are related to low blood sugar (hypoglycemia) that typically develop after eating or drinking sweets and/or carbohydrates. Mild symptoms that tend to be controlled / self-limited are very common. More severe symptoms that range from generalized weakness, lethargy, lightheadedness, and even fainting are far less common and may be troublesome in some patients.
Treatment is straightforward and consists of quickly ingesting sugary beverages or candy. Symptoms typically subside within minutes. Severe cases are rare. Unpredictable onset of severe symptoms may alter lifestyle. Several surgical options, including reversal of the RYGB, are available but are rarely required. Dr. Brolin has seen several such cases during his 36 year career (none of which developed after an RYGB performed in his practice).