Benefits & Risks of RNY Gastric Bypass
The Roux En Y Gastric Bypass is a major operation and does carry risk of complications and rarely even death which are associated with any general anesthesia or major abdominal surgery. The risk is approximately the same as having your gallbladder removed or undergoing a hysterectomy. The risk of general anesthesia in morbidly obese patients occurs regardless of the type operation and aren’t unique to bariatric surgery. Patients who are over weight and have their appendix or gallbladder removed, or undergo a hysterectomy have the same risk. The risk of a major complication overall is around 5- 8% over your lifetime from all causes. These risks can be relatively minor like a kidney infection or slow healing of an incision, all the way up to a serious life threatening complication. The most serious complications which occur early are pulmonary emboli or blood clots which can break free from the legs and travel to the lungs (0.1%); bleeding requiring further treatment such as a transfusion or re-operation (1%), or leaks and infections from the GI tract, suture or staple lines (0.25%). The most common cause of death after any bariatric surgery procedure is a pulmonary embolus (1/1000 patients on average), despite the fact we give our patients both injectable blood thinner and use special compression boots (SCD’s or Sequential Compression Devices) to massage the legs through out the hospitalization. This risk occurs with any over weight patient who has surgery for any reason and can’t be prevented. The second most common cause of death after gastric bypass is from a leak or infection. Staple line and suture line leaks, or perforations from any cause can result in peritonitis which can result in multiple re- operations, a prolonged hospitalization, and even death. (We have had 6 leaks in 2400 cases or 0.25%). We have had 5 deaths in our first 2400 cases over the past 15 years (0.2%). This is less than half the national reported incidence of 0.5% in most studies. Three patients died from pulmonary emboli despite receiving blood thinner, one patient died from a staple line leak at home after she refused to return to the hospital for treatment and one patient died from heart failure 2 months after surgery. His cardiologist had given him 2 months to live before surgery due to severe end stage heart disease which needed a heart transplant, but the surgeon wouldn’t do a transplant unless he lost weight first. Risk factors for surgery include being male, age over 50, weight over 400 pounds or BMI over 60, and having certain Co-Morbidities such as hypertension, heart or pulmonary disease (sleep apnea), or history of blood clots or venous stasis disease in the legs.
Long term risks which may require reoperation or reversal to correct include:
1). Developing a bowel obstruction due to adhesions or scar tissue associated with surgery, or due to an internal hernia due to the creation of the “Y” Roux limb. This can be very hard to diagnose in severely overweight patients and may not be apparent on xray exams therefore anytime a post op patient experiences abdominal pain or nausea and vomiting that lasts more than 4 hours, they need to contact us.
2) Develop a marginal ulcer where the pouch and small bowel are joined. There is an increase risk of this after Gastric Bypass and patients should stop smoking and avoid aspirin, NSAIDS and steroids unless they take medications (Proton Pump Inhibitor or PPI) to protect the stomach. Even with medication the risk of an ulcer is still increased.
3) Development of malnutrition, anemia, vitamin deficiencies or metabolic bone disease due to inadequate supplements. (NOTE: We test all our patients before surgery and over 25% have iron deficiency anemia preop, 30% have metabolic bone disease or thin bones, and 50% have vitamin D deficiency). Patients are at risk for iron, calcium and B vitamin deficiencies (but not only limited to these) due to the bypass of the upper small bowel called the duodenum. This may require special nutritional feeding or surgery to correct in rare instances. We recommend females not get pregnant for 18 months until their weight loss has stabilized to prevent any nutritional deficiencies or birth defects in the fetus. After 18 months the risk of pregnancy returns to normal, where as morbid obese females have an extremely high risk of infertility, miscarriages and birth defects.
4) Stoma stenosis or a narrowing of the outlet from the gastric pouch can result in chronic vomiting, solid food intolerance and excessive weight loss, which may require stretching with a balloon and gastroscopy procedure.
5) Chronic vomiting or diarrhea. This may be the result of a stoma stenosis, over eating or eating foods like desserts which cause “Dumping Syndrome” which are prohibited after gastric bypass surgery.
6) Hypoglycemia or low blood sugar occurs in some patients after meals and is a form of the dumping syndrome. This almost always occurs after consuming sweets, but can occur in some patients who eat simple carbohydrates like potatoes, bread, rice and pasta. It may not be apparent until 18-24 months after surgery. It can usually be controlled with diet modifications.
7) Weight loss failure or dissatisfaction with the restrictions of a Gastric Bypass on diet and lifestyle which may lead a patient to consider a surgical revision or reversal of their surgery.
8) Depression, Emotional and Social Issues and “Cross Addiction”. Any bariatric surgery results in significant behavioral changes and emotional stress and many patients utilized food prior to surgery to deal with emotions. After surgery this is taken away and they may struggle emotionally which may worsen depression and in rare instances lead to suicide if untreated. (See article 1 below for details) Patients may have been so emotionally dependent on food to deal with emotions that they switch to another “behavior” such as drinking alcohol, gambling, or having multiple sexual affairs after surgery; which is called “cross addiction”. This may require intensive counseling or even inpatient therapy or rehab to learn healthy ways to address these issues. Finally, bariatric surgery may place stress on a marriage, as one partner undergoes a dramatic change and the other mate feels threatened and insecure, which can cause discord and lead to divorce post op.
Benefits of Roux-En Y Gastric Bypass:
Multiple long term studies have documented improved health, resolution of co-morbidities, improved life expectancy, reduced risk of certain cancers and reduced health care costs for patients who undergo Roux En Y Gastric Bypass for morbid obesity.
Review these articles:
1) Long term mortality after gastric bypass surgery. New England Journal of Medicine 2007; 357: 753-761.
2) Surgery decreases long term mortality, morbidity and health care use in morbidly obese patients. Annals of Surgery 2004; 240: 416-424.
3) The impact of weight reduction surgery on health care costs in morbidly obese