LOUISVILLE, KY. — Extension of the Roux limb in Roux-en-Y gastric bypass procedures for “super obese” patients may provide good long-term weight loss and resolution of comorbidities with an acceptable rate of complications, Mr. Wayne K. Nelson reported at the annual meeting of the Central Surgical Association.
Surgeons at the Mayo Clinic, Rochester, Minn., developed and refined the very, very long-limb Roux-en-Y gastric bypass (RYGBP) to meet the needs of their large referral practice in bariatric surgery, which accepts patients who are more overweight and have worse comorbidities than are typically seen.
The more commonly performed RYGBP operations for super obese patients—the distal gastric bypass and the biliopancreatic diversion with or without duodenal switch—both leave a relatively short Roux limb, a relatively long biliopancreatic limb, and a short (100-cm) common channel where food and digestive enzymes mix.
The proximal anatomy of the very, very long-limb RYGBP is similar to that of the distal RYGBP, but the Roux limb is much longer (typically 400–500 cm).
The extra length leaves a longer transit and greater ability to absorb water, minerals, and vitamins, said Mr. Nelson, who is a student at the Mayo Medical School in Rochester.
The common channel is the same 100-cm length, whereas the length of the biliopancreatic limb is typically shorter—around 50–70 cm—than in other RYGBP procedures.
“Remember, this isn't a typical Roux-en-Y gastric bypass,” he said.
Of 1,435 bariatric procedures performed at the Mayo Clinic during 1985–2003, 257 were performed with the very, very long-limb RYGBP. These 257 consecutive patients were 45 years old on average, and had an average body mass index (kg/m
More than 90% of the operations were open.
When the investigators began their study, they sent a detailed survey to patients to gather data in addition to what had been captured at normal follow-up visits; 73% of the patients responded to the survey.
After an average of 45 months of follow-up, the patients' BMI had dropped to a mean value of 37, and 82% had lost more than 50% of their excess body weight, an amount commonly considered as a marker of success in bariatric surgery.
The patients who did not lose greater than 50% of their excess body weight still lost a great deal of weight, Mr. Nelson said, but many of them needed to lose hundreds of pounds to reach their ideal body weight. On average, patients lost 66% of their excess body weight.
Medical comorbidities resolved without the need for further treatment in a large number of the patients after the operation, including type 2 diabetes in 95% of patients, hypertension in 65%, sleep apnea in 48%, and asthma in 30%.
In the survey, 90% of patients reported that they were satisfied with the results of the operation, and 93% said that they would recommend the procedure.
Procedural complications included two deaths, four staple-line leaks (one of which required reoperation), two intraabdominal abscesses, five wound dehiscences, 22 wound infections, and two pulmonary emboli.
About 82% of the patients reported some food intolerance, and 70% had occasional loose or watery stools. The more serious complication of malnutrition resulting from protein or caloric deficiency developed in 4%; this was resolved with a proximal relocation of the jejunoileostomy to lengthen the common channel to 200–300 cm. Other problems included oxalate nephrolithiasis in 16% of the patients, and gross steatorrhea in 5%.
“Because of the potential metabolic sequelae, [the very, very long-limb RYGBP] should not be offered” to patients who are medically naive, noncompliant, or unreliable regarding follow-up, or who have extremely abnormal preoperative amounts of urinary oxalate, Mr. Nelson said.
EMILY BRANNAN, ILLUSTRATION