Phẫu Thuật Giảm Béo (Bariatric Surgery)

How to avoid it
In order to avoid this complication it is important to correctly select the
sites for dissection along the lesser curvature and into the phreno-gastric
ligament. A reliable reference point for dissection is the equator of the bal-
loon (calibration tube inflated with 25 cc of air and withdrawn to the
gastro-oesophageal junction) which, on the phreno-gastric ligament, cor-
responds to the left crus.
The retrogastric tunnel is created by joining the reference points. The
dissection has to be perpendicular and has to aim at the left crus. The
bursa omentalis should not be entered and the dissection has to be per-
formed into the phreno-gastric ligament above the peritoneal reflection of
Diagnosis, Prevention and Treatment of Complications
133
Figure 4.
Posterior stomach slippage.

the bursa omentalis. Once the LAP-BAND® has been positioned, an
anterior ‘embedment’ is carried out with a few retention sutures applied
from the greater towards the lesser curvature. Following these steps it is
unlikely that either the band or the stomach walls can slip.
It is unquestionable that the lower reported incidence of stomach
slippage is due to:
a)
The creation of a ‘virtual’ pouch. The smaller pouch has less ability to
stretch and pull the gastric fundus from below the band.
b)
The sound placement of retention gastro-gastric sutures.
c)
The posterior positioning of the band very high and in close proxim-
ity to the gastro-oesophageal junction. This anatomic tendency for
high posterior position is clearly evident in the pars flaccida and com-
bined pars flaccida to perigastric techniques. However, surgeons
experienced with the perigastric technique have always recommended
a high posterior position as well.
Treatment
Different options are available:
a)
Deflation: The band system is deflated via the access port and an
upper GI X-ray series is performed. This is the only way to positively
establish the cause of the symptoms, and to establish whether any
passage for the fluids exists through the band. In most cases the pouch
returns to normal size and motility. After one month the band is grad-
ually inflated with no more than 1.0 cc at a time. After deflation, if an
upper GI series still shows slippage and/or the contrast passes with
difficulty through the band, band removal or repositioning must be
performed. True stomach slippage (as opposed to gastric pouch dilata-
tion) does not respond to the above conservative measures and
indicates the need for urgent laparoscopic or open exploration of the
abdomen, especially in case of epigastric pain.
b)
Removal: The LAP-BAND® System can be removed by laparoscopy.
To reach the site of the band, which is usually covered by adhesions,
it is advisable to follow the connecting tube and pull it. The buckle of
134
M. De Luca et al.

the band is easily identified and cut along the side of the buckle,
allowing the withdrawal and removal of the device. In this case
another surgical procedure could be offered to the patient.
c)
Pull through technique: In the case of anterior gastric wall slippage,
first the band must be deflated and exposed. At this point it is feasible
to reduce the slippage by carefully pulling the gastric wall through the
band. Retention sutures are applied. If the stomach above the band has
become oedematous or hypertrophied to the extent that reduction is
not possible, the band needs to be divided and a new band placed
above the enlarged gastric pouch. Of course the position of the band
on the lesser curvature and the location of the retrogastric tunnel have
to be checked. If they are not correct, a repositioning has to be done.
d)
Repositioning: Posterior stomach slippage is treated by removal of the
band and placement of a new band higher up. The removal of the band
requires just enough dissection to give access to the part of the band
directly to the left of the buckle. The reference points for dissection
have to be identified again to be sure that the retrogastric tunnel will
be above the peritoneal reflection of the bursa omentalis. If the usual
‘perigastric’ technique for dissection and creation of the retrogastric
tunnel is not possible due to local adhesions, the ‘pars flaccida’ tech-
nique can be easily utilized. The pars flaccida pathway has not been
previously dissected and is therefore easy to access. In this case
dissection begins directly lateral to the equator of the calibration
balloon in the avascular space of the pars flaccida. After seeing the
caudate lobe of the liver, blunt dissection is continued under direct
visualization until the right crus is seen, followed immediately by the
left crus over to the angle of His.
Stoma obstruction
Stoma obstruction is defined as an obstruction to the passage of food from
the gastric pouch to the rest of the stomach.
Incidence
It can happen any time, early or late in the postoperative period.
Diagnosis, Prevention and Treatment of Complications
135

Symptoms
These include:
•
sialorrhoea;
•
vomiting;
•
dysphagia;
•
epigastric/retrosternal and chest pain;
•
inability to swallow;
•
new onset of reflux;
•
repeated aspiration and pulmonary complications in severe cases.
Causes
Stoma obstruction in the early postoperative period has a number of
possible causes all of which serve to narrow the stoma and simulate the
effect of an over-tight band:
a)
After band placement using the ‘pars flaccida’ approach, stoma
obstruction is most often associated with smaller bands applied over
a thick gastro-oesophageal junction area or too distal from the GOJ.
b)
After band placement using the ‘perigastric’ or the ‘pars flaccida to
perigastric’ approach, stoma obstruction is usually caused by the
incorporation of too much tissue inside the band. In most of the cases,
in fact, the band is positioned too distally from the GOJ causing a
large amount of fundus and stomach wall to be encompassed by the
band. Because the circumference of the band is fixed, obstruction
results.
c)
In other cases, especially in heavy male patients with thick GOJ areas
the 9.75 or 10 cm bands may be placed around too much tissue. The
surgeon can perform a delicate dissection, thinning out the area where
the band is to be placed.
d)
If a band still appears too tight just prior to locking, then consider
using the ‘two step dissection’ option. When the ‘pars flaccida’ tech-
nique has been used and when a band appears to be too tight just prior
to locking the buckle, then stop, un-thread the band tubing and back
136
M. De Luca et al.

the band out of the retrogastric space. Leave the tubing in position
behind the stomach and inflate the calibration tube to 25 cc. Pull the
tube back so the balloon is firmly stopped against the bottom of the
GOJ. Select a point at the equator (midline) of the inflated balloon on
the edge of the lesser curve (as would be done to start the perigastric
dissection). Deflate the balloon and pull the calibration tube back into
the oesophagus. Bluntly dissect straight down access port alongside
the lesser curve. Do not follow the stomach wall behind the stomach,
just dissect straight downward until the band tubing is found in the
pars flaccida pathway. Pull the band tubing up through the new peri-
gastric window and re-thread the buckle. Just before locking all the
way, confirm that the band now fits loosely. If not, excise fat tissue on
the anterior gastric wall as needed to avoid being over-tight.
e)
Post-operative oedema of the area incorporated by the band due to
haematoma or post-operative reaction.
Late stoma obstructions are usually related to:
•
gastric pouch dilation;
•
stomach slippage;
•
erosion;
•
pouchitis and/or oesophagitis caused by bad eating habits.
Diagnosis
In most of the above-mentioned cases a post-operative contrast study with
gastrographin (which must always be done on the first post-operative day)
often reveals complete obstruction or near complete obstruction with
minimal flow from the oesophagus and gastric pouch to the portion of
the stomach below the band (Fig. 5). Tertiary oesophageal contractions
(uncoordinated contractions) are usually evident.
Treatment
In many cases deflation of the band, a few days of liquid diet and medical
treatment with pump inhibitors can prove salutary. For patients with
Diagnosis, Prevention and Treatment of Complications
137

near-complete or partial obstruction, initial treatment can be conservative
consisting of rehydration and reassurance in an inpatient setting. If
patients do not improve clinically and radiologically within a few days
they can be managed with exploratory laparoscopy as described earlier. If
the stoma obstructions are caused by stomach slippage, pouch dilatation
or erosion they are treated accordingly.
Oesophageal and gastric pouch dilatation
Oesophageal and gastric pouch dilatation without stomach slippage have
been reported.16–18
Incidence
Oesophageal dilatation is a debatable complication having been observed
and reported at essentially only one site in the U.S. Food and Drug
Administration (FDA) clinical trial. In our series of 830 patients, 92 cases
138
M. De Luca et al.
Figure 5.
Stoma obstruction.

(11 per cent) of oesophageal and gastric pouch dilatation were reported.
Of these 92 cases, 83 (90 per cent) were caused by gastric slippage and
9 (0.9 per cent) by malposition of the band. It is our observation that
oesophageal dilatation is a transient clinical ‘finding’ indicative of
an overtightened band or a chronic outlet obstruction due to band malpo-
sition or slippage.
Causes
Even though the two entities, stomach slippage and gastric pouch dilata-
tion, are different from an etiopathogenic point of view, they sometimes
overlap; in a few cases the actual cause could be debatable. When this
type of pouch enlargement occurs it is most likely caused by:
•
over-inflation of the band resulting in a mechanically severe outlet
obstruction;
•
creation of an oversized pouch during surgery (band placed too low or
malpositioned);
•
patient’s lack of compliance regarding oral intake (inappropriate food
intake, insufficient chewing of food and overeating causing vomiting).
All these factors can stress and stretch the new small gastric pouch.
Eventually the pouch and even the oesophagus may dilate as occurs in
other restrictive procedures. Failure to address the issue will result in an
atonic pouch and large atonic oesophagus.
Symptoms
These are indistinguishable from those previously described for stomach
slippage.
Diagnosis
Periodic oesophageal imaging may help detect dilatation and therefore
should be conducted at least once in the first post-operative year and/or at
the time of adjustment (Fig. 6).
Diagnosis, Prevention and Treatment of Complications
139

How to avoid it
Creating a small upper pouch (15 ml or, even better, ‘virtual’) has been
demonstrated to be vital to the success of surgery. There is a dramatic
decrease in pouch enlargement problems when the initial pouch size is no
more than 15 ml or ‘virtual’. The size of the pouch and the dissection
points for the retrogastric passage of the band have to be accurately deter-
mined with the use of the calibration tube/balloon supplied with each
LAP-BAND® System.
Apart from the cases caused by an over-inflated band, we believe
most of the reported cases are due either to stomach slippage (see above)
or to malpositioning of the band. We avoid this complication by respect-
ing the reference points for dissection and carrying out the retrogastric
dissection as previously described. While creating the pouch, avoid any
cul de sac that could be a recipe for further enlargement of the pouch
leading to ‘food intolerance’. The cul de sac is avoided by removing the
calibration tube and by applying the retention sutures from below
upwards. To reduce the incidence of early food intolerance we recommend
140
M. De Luca et al.
Figure 6.
Oesophageal dilation.

that the LAP-BAND® stoma initially be kept large (band un-inflated) after
surgery. A more open stoma may help accommodate any post-operative
oedema or patient difficulty in compliance while learning new eating
habits.
Treatment
Its management involves complete deflation of the band and, after two to
three months, slow re-inflation with the surgeon being careful not to reach
the previous point of over-inflation. If, after deflation, an upper gastroin-
testinal X-ray series shows a persisting oesophageal/gastric pouch
enlargement with difficult passage of the contrast medium through the
deflated band, the surgeon is probably dealing either with stomach slip-
page or with malpositioning of the band. In both cases the device is
encompassing too much gastric tissue. Removal or repositioning of the
band is usually required in these cases (see treatment of stomach
slippage).
Erosion
Band erosion, defined as the partial or complete movement of a synthetic
band into the gastric lumen of the stomach, is also known as migration,
gastric incorporation and gastric inclusion. It exists as a possible compli-
cation following bariatric surgical procedures in which synthetic materials
(silicone, Marlex®, Dacron® etc.) are used to create the gastric stoma.
Band erosion may occur following vertical banded gastroplasty and
gastric bypass as well as after LAP-BAND® System surgery. The occur-
rence of this complication renders any weight loss procedure ineffective
and requires removal of the band, generally via surgery.20–24
Incidence
This complication occurred in 1 per cent of the patients of the LAP-
BAND® FDA clinical trial. Omitting series in the international literature
which include a large number of revision procedures and those performed
Diagnosis, Prevention and Treatment of Complications
141

during the learning curve, the LAP-BAND® System erosion rate is well
below 1 per cent.
Causes
The level of laparoscopic expertise and the extent of LAP-BAND®
System experience affect the surgeon’s ability to avoid complications. The
incidence of erosion is attributed to one or to a combination of the
following:
•
small, undetected injuries to the gastric wall that occur during band
placement;
•
necrosis due to pressure of the band;
•
access port infection.
There is some disagreement among surgeons regarding the actual evolu-
tion of this process. While some believe that first the access port becomes
infected, then the infection travels down the tubing to the band causing
erosion, most believe that the infection of the port is a symptom of an
already present erosion.
Symptoms
Most symptoms of erosion are of benign nature, non-urgent, non-life-
threatening. Ileus or sepsis are rarely found in association with the onset
of erosions. Erosions may go unnoticed for a considerable period of
time because the capsule seals off the band from the peritoneal cavity
and the band gradually transitions into the lumen without leakage or
sepsis developing. Surgeons have observed a variety of (usually
clinically benign) symptoms which may serve as indicators of band
erosion. Many of these may be seen in combination and patients may
present with:
•
weight gain without apparent cause;
•
feeling of lack of restriction/satiety;
•
ineffectiveness of band adjustments;
142
M. De Luca et al.

•
passage of contrast medium through and around then band shown on
X-ray;
•
chronic and persistent port infection (port site infection may be the
first symptom of erosion, usually due to migration of bacteria from
the stomach to the port site area along the tubing).
Diagnosis
An erosion can be diagnosed by an upper GI X-ray series, by OGDS and
by fistulography (Fig. 7).
How to avoid it
A meticulous, gentle and careful operative dissection may avoid at least
some of these erosion problems. If the surgeon suspects that an injury to
or perforation of the lumen has occurred during surgery the injury should
be addressed and serious consideration should be made as to whether
placement should proceed at that time. During surgery, placement of
Diagnosis, Prevention and Treatment of Complications
143
Figure 7.

gastro-gastric sutures over the locking mechanism (buckle) should be
avoided. This area protrudes and can cause pressure necrosis to the gastric
wall that covers it. Instead, all retention sutures should be placed to the
left side of the locking mechanism.
Treatment
The occurrence of this complication requires removal of the band by
laparoscopy. To reach the site of the band, which is usually covered by
adhesions, it is advisable to follow the connecting tube and to pull it. The
buckle of the band is easily identified and a cut on its weak part permits
removal of the band. A few stitches are applied to the damaged gastric
wall (gastrography). We usually perform a peri-operative gastroscopy and
a methylene blue test to confirm that there is no leak. We then insert a
naso-gastric tube for decompression and a perigastric drain. The surgical
approach is the same even if erosion is high enough to be considered
oesophageal. Some authors have described techniques for band removal
(usually bands other than LAP-BAND®) with an oral endoscope regardless
144
M. De Luca et al.
Figure 8.

of whether or not the band is contained completely within the gastric
lumen.
Gastric necrosis
By gastric necrosis we mean the necrosis of the upper gastric pouch.17,18
Incidence
Necrosis is very rare. In one series of 400 patients only one case (0.25 per
cent) was reported. In our own series of 1,292 patients we recently expe-
rienced our first case as well. This patient, complaining of symptoms
suggesting either gastric slippage or a gastric pouch dilatation, was hospi-
talized in a distant local hospital. Despite our suggestions about the need
for referral and for prompt appropriate treatment she was kept there for a
number of days under conservative treatment. Finally, due to the onset of
exacerbating abdominal tenderness and peritonitis, she underwent
exploratory laparotomy and gastric resection.
Causes
Gastric necrosis may occur early in the post-operative period or later
when it is likely to be the result of a long-term undetected stomach slip-
page. Stomach slippage or gastric pouch dilatation can cause the band to
exert continuous pressure against the gastric wall, which, in turn, may
decrease the blood supply to the fundus. This pressure may also result
from over-inflation of the band. The combination of decreased blood sup-
ply and continuous pressure may lead to necrosis of the gastric wall. Even
in the absence of stomach slippage, an over-distended gastric pouch by
itself can impair blood supply and progressively lead to gastric wall
necrosis. The theoretical link between stomach slippage and necrosis is
the reason stomach slippage should be considered a surgical emergency.
Symptoms
We have to consider that stomach slippage and pouch dilatation, if not
diagnosed and treated accordingly, can lead to gastric necrosis. The
Diagnosis, Prevention and Treatment of Complications
145

typical symptoms are abdominal tenderness and peritonitis. Abdominal
pain is a herald; a sign that must be responded to immediately.
Diagnosis
If the symptoms are not considered diagnostic an upper GI X-ray series
with gastrographin and an OGDS can be done.
Treatment
Repair of gastric necrosis requires exploratory laparotomy and imple-
mentation of traditional surgical approaches.
Tubing/access port problems
The access port is an essential component of the LAP-BAND® System
and its placement requires careful attention.17,18,25
Incidence
In our own series we had tubing and port problems in 11 per cent of the
cases. The complication is fairly common in most series.
Causes
In part these problems can be linked to design features at the interface
between the access port and the tubing, and in part to the method of place-
ment of the port.
Symptoms
The patient can be fully asymptomatic or he can complain of some dis-
comfort at the port site or there can be difficulties in accessing the port for
adjustment. Often the patient complains of a sudden loss in sensation of
satiety and of an increase in body weight.
146
M. De Luca et al.

Diagnosis
Absence of fluid in the system indicates that something is wrong. There
should be no ‘normal’ loss of fluid. A plain X-ray of the abdomen is
appropriate to see if there has been complete detachment of the tubing
with movement of the proximal end back into the abdomen. When in
doubt, injection of contrast medium (ConrayTM) into the system will show
the leakage in most cases. Very small leaks in the tubing, especially those
due to needle sticks, may not be obvious. Contrast media can flow along
the tubing and pool around the band.
How to avoid it
The access port should be placed lateral to the trocar opening. A pocket
must be created for the port so it is placed far enough from the trocar path
to avoid abrupt kinking of the tubing. Alternatively a smooth arching path
without sharp turns or bends may be created either with a 5 mm trocar or
a haemostat to provide a gradual entry path into the abdominal cavity or
creating a subcutaneous tunnel so that the tubing enters the abdomen
through a second trocar path. The port is usually positioned in the
left hypochondrium, sutured to the rectus fascia with 4 Prolene® suture
(Figs. 9 and 10).
Treatment
If the port has to be replaced and repositioned it can be scheduled as a day
surgery procedure. If the proximal end of the tubing is into the abdominal
cavity, laparoscopy and recovery of the tubing are needed as part of the
repair. Sometimes a lengthening of the tubing has to be made at the same
time. With the recently improved access port design we have had minimal
tubing problems since 2004.
Lack of compliance/unsatisfactory results
In case of lack of compliance or unsatisfactory results we offer the patient
the ‘bandinaro’ procedure as a second choice or as remedial surgery. This
Diagnosis, Prevention and Treatment of Complications
147

second stage consists in the addition of a biliopancreatic diversion
duodenal switch (BPD DS) to the previous LAP-BAND® (gastric preser-
vation). BPD DS has a 200 cm alimentary channel and a 50 cm common
channel (Fig. 11).1–18
148
M. De Luca et al.
Figure 9.
Creating a sub-Q tunnel so that the tubing enters the abdomen through a
second trocar path.
Figure 10.
A smooth, arching path, without sharp turns or bends in the tubing, is
optimal. A tubing path can be created with a 5 mm trocar or a haemostat (e.g. Kelly) to
provide a gradual entry path into the abdominal cavity.

Incidence
Failure to maintain long-term weight loss in adjustable gastric bandingTM
is estimated at 25 per cent.
Causes
Once the presence of slippage, pouch enlargement, erosion and tubing/port
problems have been excluded, the main reason for unsatisfactory results is
the patient’s lack of compliance with the LAP-BAND® System.
Symptoms
The patient is asymptomatic, apart from the unsatisfactory weight loss, a
couple of years after the original LAP-BAND® procedure. The patient has
been not able to change his eating habits according to the new gastric
restrictive situation.
Diagnosis, Prevention and Treatment of Complications
149
Band Inaro
Lap Band + Scopinaro
Band-Inaro
 Digestive loop = 200 cm.
 Common loop = 50 cm
 Bilio-pancreatic loop =
remainder of small intestine
Figure 11.
LAP-BAND® + Scopinaro = Band-Inaro (Bandinaro). Digestive loop =
200 cm; common loop = 50 cm; bilio-pancreatic loop = remainder of small intestine.

Diagnosis
An Upper GI X-ray Series and an OGDS have to be done in order to
exclude problems at the level of the band.
Rationale
Vassallo proposed a duodenal switch by laparotomy in addition to a tran-
sitory gastroplasty or to an absorbable band of polydioxanone, preserving
the stomach entirely, in 1997. In this series the patients experienced no
diarrhoea and/or protein deficiency. Sleeve gastrectomy was added to the
duodenal switch in order to reduce the marginal ulcer incidence and to add
some sort of restriction. Thanks to the work of De Meester we are well
aware that the preservation of 3–4 cm of viable duodenum is enough to
greatly reduce the incidence of marginal ulcers. Moreover a restriction can
be achieved by applying a LAP-BAND®, therefore avoiding a sleeve gas-
tric resection with its irreversibility, risk of bleeding, leakage and stenosis.
This procedure, being a fusion of the LAP-BAND® plus Scopinaro’s
BPD, is known as ‘Bandinaro’.
Results
From March 2001 to August 2007 the total series of patients undergoing
sequential treatment (restrictive as the first step and malabsorptive as the
second step) was 84. The malabsorptive procedure was performed laparo-
scopically in the last 58 cases.
At the time of the first LAP-BAND® operation of the series of
84 patients, mean weight was 139.3 ± 26.8; at the time of duodenal
switch operation mean weight was 118.1 ± 24.3 kg and percentage
EWL 17.2 ± 11.3; at two years mean weight was 60 kg and percentage
EWL 80.3 ± 10.4; at five years mean weight was 57.3 kg and percentage
EWL 83.1.
We registered one case of mortality for malignant hypertemia, one
case of gastro-colic bleeding requiring reoperation and two cases of
duodenal-ileal fistulas not requiring reoperation.
150
M. De Luca et al.

Conclusions
The LAP-BAND® has proven to be remarkably safe. Given the anaes-
thetic and operative risk status of these patients it is difficult to think of
any surgical procedure for them that could have a better safety record than
LAP-BAND® placement. The minimally invasive nature of the procedure —
no cutting, stapling or alteration of the anatomy — tends to keep the
complication rate down, especially for serious complications.
There are some clear requirements for the successful use of the LAP-
BAND®. Though these are not difficult or unusual, they are essential. The
surgeon needs to have good laparoscopic skill and bariatric experience.
Reasonable competence and experience can be achieved with good,
specifically-oriented training and proctoring. There must be a commitment
to the patients, to their education and support, to their ongoing routine care
and problems. This commitment is best realized in the presence of a mul-
tidisciplinary support team (dietician, psychologist, internist and surgeon).
Because of the ability to adjust the degree of restriction, the weight
loss is achieved in a gentle way. Ideally it occurs slowly over two or more
years and should not be associated with symptoms of severe restriction or
vomiting, but rather with a sense of satiety before eating and an early
sense of fullness after eating small amounts.
The LAP-BAND® is the only bariatric surgical procedure that is
entirely reversible. Patients are not trapped permanently into a state of dis-
torted anatomy that can only be undone with difficulty. It is comforting for
both the patient and the surgeon that, should the need arise, the band can
easily be removed and the stomach allowed to return to normal.1,2,7–9
Most LAP-BAND® complications are not life-threatening and, when
they do occur, many can be remedied laparoscopically.
The evolution of the procedure, with modifications to the device and
to the technique, has served to greatly reduce the incidence of complica-
tions. And, of course, avoiding complications in the first place is always
the best complications management strategy.19,26,27
We hope to have offered here a good overview of the potential com-
plications of the LAP-BAND® placement, their causes, symptoms,
prevention strategies and possible remedies. Equipped with the knowledge
that can be provided by the extensively experienced surgeons at our centre
Diagnosis, Prevention and Treatment of Complications
151

and others, newer LAP-BAND® surgeons will no doubt see the learning
curve for this procedure substantially reduced and the already low com-
plication rates diminished even further.
References
1. Favretti, F., Segato, G., Ashton, D. et al. (2007). Laparoscopic Adjustable
Gastric Banding in 1791 consecutive obese patients: 12-year results. Obes
Surg 17: 168–175.
2. Favretti, F., Cadière, G.B., Segato, G. et al. (2002). Laparoscopic banding:
selection and technique in 830 patients. Obes Surg 12: 385–390.
3. Belva, P.H., Takieddine, M., Lefebvre, J.C. et al. (1998). Laparoscopic LAP-
BAND gastroplasty: European results. Obes Surg 8: 364.
4. Dargent, J. (1999). Laparoscopic adjustable gastric banding: lessons from the
first 500 patients in a single institution. Obes Surg 9: 446–452.
5. Biesheuvel, T.H., Sintenie, J.B., Pels Rijcken, T.H. et al. (1998). Laparoscopic
adjustable silicone gastric banding for treating morbid obesity in the centre of
Amsterdam. Obes Surg 8: 360.
6. Vertruyen, M. (2002). Experience with LAP-BAND system up to 7 years.
Obes Surg 12: 569–572.
7. Belachew, M., Legrand, M.J., Defechereux, T.H. et al. (1994). Laparoscopic
adjustable silicone gastric banding in the treatment of morbid obesity, a pre-
liminary report. Surg Endosc 8: 1354–1356.
8. Chevallier, J.M., Zinzindohoue, F., Elian, N. et al. (2002). Adjustable gastric
banding in a public university hospital: prospective analysis of 400 patients.
Obes Surg 12: 93–99.
9. Forestieri, P., Meucci, L., De Luca, M. et al. (1998). Two years of practice in
adjustable silicone gastric banding (LAP-BAND): evaluation of variations of
body mass index, percentage ideal body weight and percentage excess body
weight. Obes Surg 8: 49–52.
10. O’Brien, P., Brown, W., Smith, A. et al. (1998). The LAP-BAND provides
effective control of morbid obesity — a prospective study of 350 patients fol-
lowed for up to 4 years. Obes Surg 8: 398.
11. Belachew, M., Belva, P.H., Desaive, C. (2002). Long-term results of laparo-
scopic adjustable gastric banding for the treatment of morbid obesity. Obes
Surg 12: 564–568.
152
M. De Luca et al.

12. Cadière, G.B., Himpens, J., Vertruyen, M. et al. (2000). Laparoscopic
gastroplasty (adjustable silicone gastric banding). Semin Laparosc Surg
7: 55–65.
13. Fielding, G., Allen, J. (2002). A step-by-step guide to placement of the LAP-
BAND adjustable gastric banding system. Am J Surg 184: 26S–31S.
14. Fielding, G.A., Rhodes, M., Nathanson, L.K. (1999). Laparoscopic gastric
banding for morbid obesity: surgical outcome in 335 cases. Surg Endosc 13:
550–554.
15. Cadière, G.B., Favretti, F., Bruyns, J. et al. (1994). Gastroplastie par coelio-
videoscopie: technique. J Coelio-Chir 10: 27–31.
16. Chelala, E., Cadière, G.B., Favretti, F. et al. (1997). Conversions and com-
plications in 185 laparoscopic adjustable silicone gastric banding cases. Surg
Endosc 11: 268–271.
17. Spivak, H., Favretti, F. (2002). Avoiding postoperative complications with
the LAP-BAND system. Am J Surg 184: 31S–37S.
18. Favretti, F., Cadière, G.B., Segato, G. et al. (1997). Laparoscopic adjustable
silicone gastric banding (LAP-BAND®): how to avoid complications. Obes
Surg 7: 352–358.
19. Niville, E., Dams, A. (1999). Late pouch dilation after laparoscopic adjustable
gastric and esophagogastric banding: incidence, treatment and outcome. Obes
Surg 9: 381–384.
20. Carbajo Caballero, M.A., Del Olmo, J.C.M., Blanco Alvarez, J.I. et al. (1998).
Intragastric migration of laparoscopic adjustable gastric band (Lap-Band) for
morbid obesity. J Laparoendosc Adv Surg Tech 8(4): 241–244.
21. Meir, E., Van Baden, M. (1998). Adjustable silicone gastric banding (ASGB)
and band erosion (BE). Obes Surg 8: 385.
22. Meir, E., Van Baden, M. (1999). Adjustable silicone gastric banding and
band erosion: personal experience and hypotheses. Obes Surg 9: 191–193.
23. Mittermair, R.P., Weiss, H., Nehoda, H. et al. (2002). Uncommon intragastric
migration of the Swedish adjustable gastric band. Obes Surg 12: 372–375.
24. Baldinger, R., Mluench, R., Steffen, R. et al. (2001). Conservative manage-
ment of intragastric migration of the Swedish adjustable gastric band by
endoscopic retrieval. Gastrointest Endosc 53: 98–101.
25. Fabry, H., Van Hee, R., Hendrickx, L. et al. (2002). A technique for preven-
tion of port complications after laparoscopic adjustable silicone gastric
banding. Obes Surg 12: 285–288.
Diagnosis, Prevention and Treatment of Complications
153

26. Weiner, R., Bockhorn, H., Rosenthal, R. et al. (2001). A prospective ran-
domized trial of different laparoscopic gastric banding techniques for morbid
obesity. Surg Endosc 15: 63–68.
27. Belachew, M., Zimmermann, J.-M. (2002). Evolution of a paradigm for
laparoscopic adjustable gastric banding. Am J Surg 184: 21S–25S.
154
M. De Luca et al.

Chapter 7
Roux-en-Y Gastric Bypass
Bruno Dillemans and Sebastiaan Van Cauwenberge
Introduction
Overweight and obesity are widespread in industrialized and rich nations
and the incidence is growing at an alarming rate. The World Health
Organization (WHO) has now coined the term globesity (global obesity)
to highlight the growth of this worldwide problem.
With respect to durable weight reduction, bariatric surgery is
the most effective long-term treatment for obesity with the greatest
chances for amelioration and even resolution of obesity-associated
complications.
Roux-en-Y gastric bypass (RYGB) usually is considered to be the
standard bariatric surgical procedure. Excellent sustained weight loss and
profound improvement in medical co-morbidities can dramatically
change the lives of patients.
In this chapter we will focus first of all on the history of the proce-
dure and explain its working mechanism. The preoperative assessment of
the patient undergoing RYGB surgery will be discussed. Afterwards we
will describe some technical issues regarding the operative technique.
Since complications are inherent to surgery, we explain the most fre-
quently encountered problems and side effects after RYGB and their
management.
155

156
B. Dillemans and S. Van Cauwenberge
Background and history of gastric bypass surgery
Gastric bypass was first performed by Mason and Ito in 1966.1 In this
variation, a horizontal distal gastrectomy was performed to create a gas-
tric reservoir to which a loop of jejunum was anastomosed.
In 1977, Alden et al. created a stapled pouch without dividing the
stomach. The same year, Griffen et al. reported Roux-en-Y gastric bypass
(RYGB). Since then, there have been ongoing innovations in the tech-
nique, especially in the restrictive component.2,3 Torres et al. applied a
vertical gastric pouch, Linner et al. reinforced the gastrojejunal anasto-
mosis with a band, Salmon combined vertical gastroplasty with distal
bypass, and Fobi introduced the silastic ring proximal to the divided ver-
tical gastrojejunostomy.4–7
Current variations in the surgical technique include the method by
which the gastric pouch is created, the technique of gastrojejunostomy, and
the configuration and length of the alimentary and biliopancreatic limbs.
Those issues will be discussed below in the section Technical aspects of the
laparoscopic RYGB (LRYGB) procedure. With the increase in the per-
formance of the LRYGB, first popularized by Wittgrove and Clark, the
effect of these alterations on outcomes has been studied extensively.8
Another type of gastric bypass is the laparoscopic mini-gastric bypass
(LMGBP), first reported by Rutledge.9 In this procedure a gastric pouch
is created and a point selected on the small bowel about 200 cm distal to
the ligament of Treitz. The jejunal loop is brought up antecolic, and a sta-
pler is used to anastomose the stomach and the small bowel at this point.
Comparing the five-year trend from 2003 to 2008 regarding the
evolution of RYGB surgery, markedly different trends were found for
Europe and USA/Canada. In Europe, RYGB increased from 11.1 per cent
to 39.0 per cent, whereas in USA/Canada, RYGB decreased from 85.0 per
cent to 51.0 per cent.10
Physiology of the Roux-en-Y Gastric Bypass
Body weight is the result of complex physiologic mechanisms that control
food intake and energy expenditure. Regulation of body weight involves
several systems such as the adipose tissue, the hypothalamus and the

adrenal glands, which are linked by neural and hormonal signals. Recent
investigations have identified several key molecules that regulate food
intake, including ghrelin, neuropeptide Y (NPY) and melanocortins, and
have focused on the relationship between obesity and leptin levels.11
It is commonly believed that the RYGB induces weight loss through a
combination of mechanisms, including decreasing the capacity of the
stomach, restricting the rate of emptying of the pouch, prohibiting the
intake of high osmolar foods, and causing selective malabsorption of fat.
Although convincing data of the relation between gastric pouch or stomal
size and achieved weight loss are lacking, the restriction of food is consid-
ered as the major causative factor of successful weight loss after the gastric
bypass. Moreover, the majority of patients with weight regain after an ini-
tial good success of their gastric bypass, do complain of a loss of restriction
and satiety when eating, explaining an increased caloric intake. The mal-
absorptive component of the gastric bypass is believed to be less important
than the restrictive part; at least in the proximal type of gastric bypass.
Studies have showed that the serum albumine and faecal fat are not altered
after a gastric bypass, and no major malabsorption of anticancer agents
after a gastric bypass has been reported yet.12 The hormonal effect of the
gastric bypass is probably more important, although not fully understood
yet. By enabling salivary secretions and meals going directly into the dis-
tal jejunum, RYGB might stimulate the release of gut hormones, which
inhibit the brain appetite centre or cause the feeling of nausea. The obser-
vation that RYGB induces resolution of type 2 diabetes mellitus prior to the
occurrence of weight loss further suggests that the mechanism of action of
this operation might involve some endocrine effects.11
A number of peptides released from the gastrointestinal tract have
recently been shown to regulate appetite and food intake, effecting both
orexigenic and anorexic outcomes through actions on the hypothalamic
arcuate nucleus. Ghrelin, a hormone produced from the stomach in the
preprandial state, increases expression of the orexigenic hypothalamic NPY
and stimulates food intake in rodents and humans. In contrast, peptide YY
(PYY), released postprandially from the distal gastrointestinal tract, acts
within the arcuate nucleus to inhibit the release of NPY. Intravenous
PYY3–36 infusions into humans and intraperitoneal injections into rodents
induce satiety and reduce food intake. Glucagon-like peptide 1 (GLP-1) acts
Roux-en-Y Gastric Bypass
157

mainly as an incretin, promoting postprandial insulin release and improving
pancreatic β-cell function,and has also been reported to inhibit food intake
in humans. Pancreatic polypeptide (PP) has recently been shown to inhibit
appetite and food intake and promotes energy expenditure.13
Le Roux et al. demonstrated a pleiotropic endocrine response to bariatric
surgery, which might account for the appetite reduction that leads to long-
term changes in body weight. They have shown that following RYGB,
patients have increased postprandial PYY and GLP-1 favouring enhanced
satiety to a meal. Furthermore, RYGB patients experience early and exag-
gerated insulin responses, potentially mediating the improved glycaemic
control in patients with type 2 diabetes mellitus. None of these effects were
observed in patients losing similar weight through gastric banding (GB),
suggesting that the hormonal changes are not secondary to weight loss alone.
They further demonstrated in a rodent model of intestinal bypass that
elevated PYY may have a causative role in mediating reduced food intake.13
The authors propose that the higher postprandial PYY response after
gastric bypass surgery due to the altered intestinal anatomy may con-
tribute to the patients’ increased satiety and weight loss. RYGB is thought
to be significantly more effective than restrictive procedures such as ver-
tical banded gastroplasty for weight loss in morbid obesity, especially for
patients addicted to sweets. The banding patients did not have an exag-
gerated PYY response. There are no direct comparisons of satiety between
RYGB and GB, although reports indicate that patients do experience sen-
sations reported as enhanced satiety after GB and RYGB.
In both rodent and human studies, high GLP-1 was observed in par-
allel with PYY. GLP-1 is produced from the same entero-endocrine cells
(L cells) as PYY and acts as an incretin, releasing insulin and improving
pancreatic β-cell function in rodents. Reduction in food intake has also
been reported. Previously, increased GLP-1 concentrations have been
shown following intestinal bypass. Consistent with previous RYGB
studies, the study of le Roux found no difference in fasting GLP-1 levels
but demonstrates an exaggerated GLP-1 response following a 420 kcal
meal in gastric bypass subjects. The increased GLP-1 response may con-
tribute as a satiety signal and incretin. Glycaemic control in type 2 diabetes
mellitus patients improves following RYGB surgery and often before
significant weight loss occurs.13
158
B. Dillemans and S. Van Cauwenberge

Ghrelin was initially associated with appetite reduction following gas-
tric bypass. The reduced appetite following gastric bypass was explained
by the failure of ghrelin to show the expected rise observed in diet-
induced weight loss. However, a series of publications have since shown
inconsistent ghrelin changes after RYGB and GB. These studies have
recently been reviewed, and the heterogeneity of the findings makes it
unlikely that ghrelin has a major role in the weight loss after RYGB. In
the study of le Roux et al., both bypass and banding patients had lower
fasting ghrelin levels compared with lean control subjects, although these
levels were similar to those of the obese control subjects. In agreement
with the majority of studies, the authors did not find an anticipated
compensatory rise in ghrelin among surgical subjects.
Patients treated for obesity with gastric bypass therefore have alter-
ations of several peripheral signals that potentially contribute to their
reduced appetite and enhanced glucose homeostasis. An exaggerated post-
prandial PYY and GLP-1 might combine to enhance satiety, leading to a
long-term reduction in calorie intake, while increased GLP-1 and insulin
might contribute to immediate improvements in glycaemic control.13
Preoperative Evaluation
Morbidly obese patients undergoing gastric bypass have multiple issues
regarding their co-morbidities and as in many centres, require a multidis-
ciplinary team approach. The preoperative evaluation is similar for all
bariatric procedures. The components include determining a patient’s
indications for surgery, identifying issues which may interfere with the
success of the surgery and assessing and treating co-morbid diseases.
Typical assessment includes nutritional evaluation, medical assessment
and psychological testing.14
Nutritional evaluation
The dietician is an integral part of the multidisciplinary bariatric team and
will be responsible for nutritional assessment, diet education regarding
postoperative eating behaviours and preoperative weight loss efforts.15
Preoperative very-low-calorie diet for six weeks has been shown to reduce
Roux-en-Y Gastric Bypass
159

liver volume by 20 per cent and to improve access to the upper stomach
during laparoscopic surgery, with 80 per cent of the volume change occur-
ring in the first two weeks.15,16 It has been shown that patients who are
able to achieve 10 per cent EBWL preoperatively have shorter hospital-
ization and more rapid weight loss.17 No evidence-based, standardized
dietary guidelines exist for either pre- or postoperative nutritional man-
agement of the bariatric patient. Further studies and clinical trials are
required to help define the role of the dietician in the bariatric team.
Medical Evaluation
Laparoscopic RYGB for obesity is a major procedure and can have severe
postoperative complications, hence a thorough history and physical exam-
ination with systematic review is used to identify co-morbidities that may
complicate the surgery. Consultation with a medical subspecialist is often
necessary to optimize medical conditions to reduce peri- and post-
operative risk. Routine laboratory evaluation typically includes complete
blood count, metabolic profile, coagulation profile, lipid profile, thyroid
function tests and ferritin. Vitamin B12, and fat-soluble vitamin levels
may be evaluated if considering a malabsorptive procedure.
Cardiovascular evaluation includes electrocardiogram and possible stress
test to identify occult coronary artery disease. Respiratory evaluation may
include chest X-ray, arterial blood gas and pulmonary function tests. Sleep
apnoea, if suspected on the basis of Epworth score, may be diagnosed by
sleep study and the patient started on continuous positive airway pressure
prior to surgery. Upper endoscopy may be used if suspicion of gastric
pathology exists. If Helicobacter pylori infection is present, preoperative
therapy is advised.18 The liver may be assessed by hepatic profile and
ultrasound. In cases of suspected cirrhosis, biopsy may be indicated.
Ultrasound may be used to detect gallstones, allowing the surgeon to
decide on concomitant cholecystectomy.19
Psychological Evaluation
Patients referred for bariatric surgery are more likely than the overall
population to have psychiatric problems such as social phobia,
160
B. Dillemans and S. Van Cauwenberge

obsessive–compulsive disorder, substance abuse/dependency, binge-eating
disorder, post-traumatic stress disorder, generalized anxiety disorder and
depression.20 Patients with psychiatric disorders may have a suboptimal
outcome after bariatric surgery. However, no consensus recommendations
exist regarding preoperative psychological evaluation.21 It is not certain
which psychosocial factors predict success following bariatric surgery, yet
many surgeons exclude patients who are illicit drug abusers, have active
uncontrolled schizophrenia or psychosis, severe mental retardation, heavy
alcohol use, or lack of knowledge about the surgery.22
Technical Aspects of the Laparoscopic RYGB Procedure
Various techniques of laparoscopic RYGB have been described. In gen-
eral the procedure consists of partitioning the stomach with surgical
stapling devices in order to create a small gastric pouch. This pouch is the
restrictive part of the construction. The pouch is then connected with a
loop of small bowel that has been transected 30–50 cm below Treitz. The
small bowel limb is measured at a certain length and reconstructed in a
Roux-en-Y fashion to restore the continuity. This ‘alimentary limb’ is
responsible for the malabsorptive part of the procedure.
Some technical key-steps have been the subject of extensive discus-
sion. These debates focus on:
•
Construction and size of the gastric pouch;
•
Construction of the gastrojejunostomy (handsewn, linear or circular
stapled);
•
Antecolic versus retrocolic placement of the alimentary limb;
•
Length of the alimentary limb;
•
Construction and closure of the jejuno-jejunostomy;
•
Closure versus non-closure of the mesenteric defects.
Construction and size of the gastric pouch
The restriction imposed by a small pouch size is one of the most impor-
tant aspects of RYGB. The goal of most bariatric surgeons has been to
construct small volume pouches in the proximal stomach to restrict the
Roux-en-Y Gastric Bypass
161

intake of food. To date, a gastric pouch with a volume of 20–30 ml is
generally accepted as the standard volume.
Construction of the gastrojejunostomy
A variety of surgical techniques has been developed for the establishment
of the gastrojejunostomy such as the circular-stapled anastomosis, the
linear-stapled anastomosis, and the totally hand-sewn anastomosis.
In the circular technique the anastomosis is performed with a circular
stapler with a diameter of 21 or 25 mm. The anvil of the circular stapler
can be introduced either transabdominally or transorally (e.g. the Orvil
method).
In the linear stapled gastrojejunostomy, a stab opening is made in the
gastric pouch and one in the jejunum that has been pulled up. A 45 mm
linear stapler is then introduced with one jaw in the stomach and one jaw
in the jejunum to perform the anastomosis. The common stab opening is
then closed with a resorbable suture. After this step one has to transect the
proximal small bowel to complete the anastomosis.
The hand-sewn anastomosis is usually performed in a standard
2-layer fashion with resorbable sutures,running and interrupted, and sized
with an intraluminal 32 Fr tube.
Strictures at the gastrojejunostomy, leading to vomiting, dysphagia,
nausea, solid food intolerance, or even severe dehydration, are a well-
known complication following RYGB. Different stricture rates have been
described for the three techniques ranging from 0.8 to 33 per cent,
depending on the diameter of the anastomosis and the learning curve.
While in circular-stapled anastomosis, the inner diameter of the gastroje-
junostomy is well defined, in hand-sewn anastomosis or in linear-stapled
anastomosis, in the absence of a calibration tube, the inner gastrojejunos-
tomy diameter might differ, although it is assumed to be larger than in
circular-stapled anastomosis.23
Antecolic versus retrocolic placement of the alimentary limb
The alimentary limb can be pulled up to the level of the gastric pouch in
two ways. In the first method the small bowel is pulled over the transverse
162
B. Dillemans and S. Van Cauwenberge

colon (antecolic). In most cases division of the greater omentum is then
necessary to facilitate the positioning of the alimentary limb and to limit
traction on the gastro-jejunal anastomosis. Another technique is to make
an opening in the mesentery of the transverse colon to pull up the jejunum
through this opening (retrocolic). The small bowel limb might then be
positioned either antegastric or retrogastric (i.e. in relation to the excluded
stomach). The retrocolic retrogastric pathway is considered as the most
traction-less method as this is the shortest anatomical distance to the gas-
tric pouch.
Intestinal obstruction has been reported following RYGB surgery
depending on the position of the alimentary limb. There is controversy
about whether the alimentary limb should be placed in the retrocolic or
antecolic position.
In a study of 754 patients, a greater incidence of intestinal obstruction
and internal hernia was observed in the retrocolic technique group than in
the antecolic technique group undergoing LRYGB. The results of this
study have shown that the use of the retrocolic technique is a risk factor
for intestinal obstruction after LRYGB.24
Length of the alimentary limb
The ideal length of the gastric bypass limbs is debated. RYGB that is
performed with a long Roux limb seems to result in greater weight loss
than shorter Roux limb procedures in super-obese patients (BMI >
50 kg/m2). Conversely, longer Roux limb procedures do not provide
greater weight loss in less obese (BMI < 50 kg/m2) patients.25–27 The def-
inition of a long and short Roux limb varies however according to the
different authors; with a long limb mostly counting around 150 cm and a
short one around 75 cm. Modest elongation of the Roux limb in the range
of 150–200 cm does not result in more frequent nutritional sequelae com-
pared with shorter Roux limb procedures. Conversely, RYGBs, in which
the Roux or the biliopancreatic limb is very long with anastomosis to the
mid or distal ileum (very, very long), usually results in more metabolic
problems than RYGBs in which the Roux limb measures up to 150 cm and
the biliopancreatic limb is short.28
Roux-en-Y Gastric Bypass
163

164
B. Dillemans and S. Van Cauwenberge
Construction and closure of the jejuno-jejunostomy
Many surgeons utilize a single stapling technique and subsequently close
the enterotomy with a running suture. Others utilize a double or even a
triple stapling technique to anastomose and close the small bowel.
Closure versus non-closure of the mesenteric defects
There are three sites where an internal hernia after RYGB may occur:
1.
through the transverse mesocolon defect;
2.
through the entero-enterostomy mesenteric defect;
3.
through the space between the mesentery of the Roux limb and trans-
verse mesocolon (the so-called Petersen’s space).
The increased incidence of internal hernia after LRYGB has been pri-
marily attributed to the reduced formation of postoperative adhesions
following laparoscopy. Another technical feature recognized as having a pos-
sible role in the occurrence of internal hernia is the placement of the Roux
limb. There is evidence that the majority of internal hernias (69 per cent)
occur at the transverse colon mesenteric defect. The hypothesis that the
antecolic RYGB is followed by a lower incidence of internal hernias com-
pared to the retrocolic counterpart is confirmed in a lot of scientific reports.
Even though accurate closure of all mesenteric defects does not avoid
this complication, closure is recommended because it resulted in a
reduced incidence of internal hernias in several studies.29 We have com-
pletely standardized Fully Stapled Laparoscopic Roux-en-Y gastric
bypass (FS-LRYGB) to minimize its sometimes substantial morbidity and
mortality.30
In the next section we describe our technique in detail.
Operative Technique of the Fully Stapled Laparoscopic
Roux-en-Y Gastric Bypass
Patient positioning and trocar placement
The patient is placed in the supine position, split-leg with reverse
Trendelenburg position. All patients get a flexion of the hips to help

increase surgical abdominal workspace.31 The surgeon stands between the
legs. A video monitor is positioned at the level of the patient’s head. A 30°
angle scope is used. Abdominal insufflation with carbon dioxide (CO2) is
achieved using a Veress needle. Intra-abdominal pressures are maintained
at 15 mmHg.
A five-port technique is employed: a 10 mm port 10–15 cm below the
xiphoid process, a 5 mm port high epigastric on the midline, a 12 mm port
in the right upper quadrant and two 12 mm ports in the left upper quad-
rant. The latter two ports are placed on the same line as the 10 mm port,
while the 12 mm port in the right upper quadrant, somewhat higher above
the same line (sub costal) (Fig.1).
Creation of the gastric pouch
A small window is made between the lesser omentum and the lesser
curvature of the stomach, entering the lesser sac 5–6 cm below the gastro-
oesophageal junction (Fig. 2a). At this point a linear stapler (Endo GIA™
Roux-en-Y Gastric Bypass
165
Figure 1.
Trocar port sites for fully stapled laparoscopic Roux-en-Y gastric bypass.

166
B. Dillemans and S. Van Cauwenberge
(a)
(b)
Figure 2.
Creation of the gastric pouch. (a) Start of the dissection at the lesser curvature
5–6 cm below the gastro-oesophageal junction. (b) The first linear stapler cuts the stomach
horizontally.
Universal Stapler System, Covidien, USA or Echelon™ 60 Endopath
Stapler, Ethicon, USA), usually with a blue cartridge, is introduced
through this window and the stomach cut horizontally over a distance of
50 mm (Fig. 2b).
A second linear 60 mm stapler is then introduced and fired to verti-
cally transect the stomach using a 34 Fr. orogastric tube as a guide
(Fig. 3a). The next step consists of dissection and opening of the angle of
His (Fig. 3b). Posterior to the stomach the dissection is completed to cre-
ate a window at the angle of His. Finally, the pouch is completed by
vertically firing one or two more 60 mm cartridges in the direction of and
through the latter created window, along the gastric tube (Fig. 3c).
Creation of the gastro-jejunostomy
A small opening is made in the lower left corner of the pouch (Fig. 4a),
the opening stretched and a purse-string suture is sewn using an
absorbable monofilament suture (PDS* II 3/0, Ethicon, USA) (Fig. 4b).
A 25 mm Premium Plus CEEA™ (Covidien, USA) is then introduced
intra-abdominally via the most left lateral, manually-dilated trocar open-
ing. The anvil is brought into the gastric pouch opening and the
purse-string tied (Fig. 5).

Roux-en-Y Gastric Bypass
167
(a)
(b)
(c)
Figure 3.
(a) Vertical transection of the stomach along a 34 Fr. orogastric tube.
(b) Opening of the angle of His. (c) Final stapling at the angle of His.
(a)
(b)
Figure 4.
Creation of the gastrojejunostomy. (a) Opening of the gastric pouch in the
lower left corner. (b) Purse-string suturing with PDS 3/0.

Thereafter, the greater omentum is lifted and divided up to the left
side of the transverse colon (Fig. 6a). Next the ligament of Treitz is iden-
tified and a loop of jejunum is antecolically pulled up from this point to
the gastric pouch (Fig. 6b).
An enterotomy is created 30–50 cm from Treitz and the Premium Plus
CEEA™ introduced over 5–6 cm in the jejunal loop via this opening in the
distal direction (Fig. 7a). We then perforate the jejunum under slight traction
with the spike, remove the spike and connect the stapler to the anvil (Fig. 7b).
168
B. Dillemans and S. Van Cauwenberge
(a)
(b)
Figure 6.
(a) Division of the greater omentum. (b) Identification of the ligament of Treitz.
Figure 5.
Introduction of the anvil of the circular stapler and tying of the pursestring.

The anastomosis is completed by closing and firing the instrument.
The remaining small bowel loop with the previously created opening is
then resected 1 cm proximal to the gastrojejunostomy using a linear sta-
pler with a 60 mm white cartridge so as to avoid a long blind loop of
jejunum (Fig. 8).
Roux-en-Y Gastric Bypass
169
Figure 7.
(a) Enterotomy 30–50 cm from the angle of Treitz. (b) Antimesenteric perfo-
ration of the jejunum with the spike after introduction of the circular stapler.
(a)
(b)
Figure 8.
Finalization of the anastomosis by transection of the remaining small bowel
1 cm proximal to the gastrojejunostomy.

Creation of the jejuno-jejunostomy
The length of the alimentary limb is a standard 130 cm. In patients with
BMI > 50 kg/m2, 200 cm is measured and an antimesenteric opening is
created both in the alimentary and the biliopancreatic limb (Fig. 9a, b). A
linear 60 mm stapler with a white cartridge is introduced in both openings
in order to establish a side-to-side anastomosis (Fig. 9c).
The resulting enterotomy defect is lifted by three holding stitches
(PDS* II 4/0, Ethicon, USA) and then longitudinally closed using a simi-
lar stapler (Fig. 10a). The final step is transecting the remaining blind loop
of the biliopancreatic limb, also with a similar linear stapler, and removal
of the piece of bowel (Fig. 10b).
170
B. Dillemans and S. Van Cauwenberge
(a)
(b)
(c)
Figure 9.
Creation of the jejuno-jejunostomy. (a) Antimesenteric opening in the alimen-
tary limb. (b) Antimesenteric opening in the biliopancreatic limb. (c) Side-to-side
anastomosis with a linear 60 mm stapler.

Roux-en-Y Gastric Bypass
171
(a)
(b)
Figure 10.
Creation of the jejuno-jejunostomy. (a) Closure of the enterotomy defect using
three stay sutures. (b) Transection of the remaining blind loop of the biliopancreatic limb.
Testing of the gastro-jejunostomy
A leakage test is done by forcefully injecting methylene blue through the
orogastric tube at the level of the gastrojejunostomy anastomosis. The
gastrojejunostomy is reinforced if necessary with some additional stitches
of an absorbable monofilament suture (PDS* II 4/0, Ethicon, USA)
(Fig. 11).
To prevent postoperative bleeding all staple lines are inspected under
an elevated systolic arterial pressure above 140 mmHg.28
The left lateral trocar port site, which was enlarged to introduce the
Premium Plus™ CEEA, is closed with the help of the Endo Close™
trocar site closure device (Covidien, USA) to prevent ‘lateral entrapment’
or herniation (Fig. 12).
Complications of Roux-en-Y Gastric Bypass
Laparoscopic gastric bypass has a similar spectrum of complications in
comparison to any other major laparoscopic procedure. The two most
important independent risk factors in relation to complications are male
gender and patient size. Age has also been reported to be a risk factor.
Though bariatric surgery can be performed on older patients, there is a
higher morbidity and mortality rate if complications were to occur.

Similarly patients with oxygen dependent hypoxia and atherosclerotic
cardiovascular disease are at a higher risk.
Mortality
Mortality is uncommon, ranging from 0 to 1.5 in various reports. The
mortality rate seems to be slightly higher in the open than in the laparo-
scopic RNY bypasses, but this may be the result of patient selection.32–34
172
B. Dillemans and S. Van Cauwenberge
Figure 11.
Additional reinforcement stitch at the level of the gastrojejunostomy.
Figure 12. Closure of the left lateral trocar port site with the Endo Close™ trocar site
closure device.

In the two meta-analyses published by Buchwald et al. the mortality
in the subgroup of gastric bypasses dropped from 0.5 per cent (2004) to
0.16 per cent in 2007.35,36 The major reasons for mortality were leaks and
pulmonary embolisms.
In autopsy series, leaks were responsible for approximately 50 per cent
of deaths.37
Anastomotic leaks
Leakage rates
The reported leak rate following gastric bypass is between 0 and 5.6 per cent,
with the average leak rate between 2 and 3 per cent.38–41 The most common
site of a leak is the anastomosis at the gastrojejunostomy, but in addition
other leaks secondary to staple line failure in the divided gastric pouch or
excluded stomach are also commonly reported as ‘anastomotic leaks’.
Age, gender and BMI were associated with gastrointestinal leaks after
laparoscopic Roux-en-Y gastric bypass procedures. Others had also found
that leaks are more common in men and in those patients with higher
BMI. Revisional surgery, age and diabetes mellitus have been noted to
produce higher leak rates.41
Aetiology of leakage
The aetiology of anastomotic leaks is multifactorial. Ischaemia, excessive
tension on the anastomosis, infection and surgeon’s experience are impli-
cated in its aetio-pathogenesis.42 There is no significant difference in leak
rates between the open and laparoscopic approach, neither between the
different types of gastrojejunostomy or jejunojejunostomy construction.
Reinforcement of anastomotic staple/suture lines with either bovine peri-
cardial strips or fibrin glue may decrease the frequency of leaks.43,44
Diagnosis
Early symptoms of a leak are sometimes subtle and require clinical vigi-
lance for signs such as tachycardia, respiratory distress and low-grade
fevers.45
Roux-en-Y Gastric Bypass
173

A leak may be radiographically confirmed by upper gastrointestinal
series with gastrografin swallow, but its sensitivity is reported to be low
(22 per cent).45 Computed tomography scans should be done with the admin-
istration of contrast materials (intravenous and oral). In order to increase the
sensitivity of the study, patients should take 30–60 cc of oral contrast mate-
rial immediately before the study to opacify the gastric pouch and its
connection to the Roux limb. The CT scan renders a better assessment of the
proximal portion (excluded stomach) (100 per cent), proximal efferent Roux
limb (99 per cent) and gastric pouch (96 per cent) than the distal portion
jejunostomy (67 per cent) of the Roux-en-Y gastric bypass anatomy.46
Management of leakage
Because of the rapid progression to sepsis in these patients with co-mor-
bidities, prompt exploratory surgery is warranted. Furthermore surgeons
should have a low threshold for operative management in patients who
exceed weight limitations for adequate radiological evaluation. In patients
for whom the diagnosis is unclear, a diagnostic celiotomy or laparoscopy
is an integral part of the treatment algorithm of suspected anastomotic
leaks. The mainstay of treatment of leaks is operative, with the specific
goals of achieving wide and adequate drainage, correcting the underlying
defect and accessing the excluded stomach.47
Pulmonary embolus
Pulmonary embolus (PE) remains one of the leading causes of early mor-
tality following gastric bypass and was the second most important cause
(30 per cent) in autopsy series.37 In the same study, 80 per cent had silent
pulmonary emboli despite prophylaxis. The frequency of PE and deep
vein thrombosis (DVT) is approximately 0–3.3 per cent with laparoscopic
bypasses38,39 and 0.3–1.9 per cent with open bypasses.48,49 Though there is
no optimal strategy for preventing DVT/PE, most bariatric surgeons use
both pneumatic compression devices in conjunction with subcutaneous
low molecular weight heparin. Diagnosis is made by nuclear lung scan,
CT-angiography and lower extremity duplex scan; but immediate antico-
agulation is prescribed for patients for whom there is a high level of
174
B. Dillemans and S. Van Cauwenberge

clinical suspicion. Low molecular weight heparin (LMWH) is prescribed
in most centres for an extended period after discharge from the hospital.
Bleeding
Bleeding after gastric bypass has been described in 0.6–4.0 per cent of
patients.38,40,50 Early bleeding typically occurs from one of the surgical
anastomotic and/or staple lines, and may be intra- or extra-luminal,
although it is most commonly intra-luminal. Patients frequently present
with tachycardia, a decreased haematocrit and melena.51 Such bleeding
typically resolves without surgical intervention, but may require transfu-
sion of blood products and reversal of anticoagulation. Careful endoscopic
examination and therapy is appropriate for on-going bleeding with trans-
fusion requirements. Surgery is reserved for haemodynamic instability or
continued bleeding despite restoration of normal coagulation status.50,51
Late bleeding from the gastric remnant is typically secondary to peptic
ulcer disease and can be a diagnostic and therapeutic dilemma.
Gastric remnant distension
Gastric remnant distension is a rare but potentially lethal complication fol-
lowing gastric bypass.52 The gastric remnant is a blind pouch and may
become distended if paralytic ileus or distal mechanical obstruction occurs
postoperatively. Iatrogenic injury to vagal fibres along the lesser curvature
may also contribute, possibly by leading to impaired emptying of the
bypassed stomach. Progressive distension can ultimately lead to rupture,
spillage of massive gastric contents and subsequent severe peritonitis.53
The combination of the large size of inoculum (litres) and the injurious
contents (acid, bile, pancreatic enzymes and bacteria) makes this compli-
cation more serious than leakage occurring at the gastrojejunostomy.
Clinical features include pain, hiccups, left upper quadrant tympany, shoul-
der pain, abdominal distension, tachycardia or shortness of breath.
Radiographic assessment may demonstrate a large gastric air bubble.
Treatment consists of emergent operative decompression with a gas-
trostomy tube or percutaneous gastrostomy.54 Immediate laparotomy and
Roux-en-Y Gastric Bypass
175

decompression is required if percutaneous drainage is not feasible or if
perforation is suspected.
Wound infection
Rates of wound infection are significantly greater with open (10–15 per cent)
than laparoscopic (3–4 per cent) gastric bypass procedures.39,55 The incidence
of wound infections can be decreased by prophylactic perioperative admin-
istration of antibiotics (e.g. co-amoxiclav).
Stomal stenosis
In gastric bypass, the pouch is constructed with a capacity of 20–30 ml,
and gastrojejunostomy should have a diameter of 10–12 mms. Stomal
stenosis has been described in 6–20 per cent of patients who have under-
gone RYGB.33 Several technical factors such as size of anastomosis, the
retrocolic or antecolic positioning of the roux limb, tissue ischaemia or
increased tension are known to be responsible for the stomal stenosis. The
rate of anastomotic stricture was significantly lower using the 25 mm cir-
cular stapler than the 21 mm.56 Patients typically present several weeks
after surgery with nausea, vomiting, dysphagia, gastro-oesophageal reflux
and eventually an inability to tolerate oral intake. The diagnosis is usually
established by endoscopy or with an upper gastrointestinal series.
Gastroscopic balloon dilation is usually successful.57,58 Repeat dilation
sessions may be required for some patients. The complication rate for
dilation is approximately 3 per cent. Surgical revision (required in less
than 0.05 per cent of patients) is reserved for those who have persistent
stenosis despite repeated dilations.59
Marginal ulcers
Marginal ulcers develop in 0.6–16 per cent of patients.58,60 Causes of
marginal ulcers include:61,62
•
Larger pouch size, poor tissue perfusion due to tension or ischemia at
the anastomosis;
176
B. Dillemans and S. Van Cauwenberge

•
Presence of foreign material, such as staples or nonabsorbable suture
(stitch ulcers);
•
Excess acid exposure in the gastric pouch due to gastrogastric fistu-
las;
•
Nonsteroidal anti-inflammatory, steroid drug use;
•
Helicobacter pylori infection;
•
Smoking, alcohol;
•
Critical illness, burns.
Diagnosis of a marginal ulcer is usually established by upper endoscopy.
Initial medical treatment consisting of gastric acid suppression with or with-
out the addition of sucralfate is successful in the majority of patients
(95 per cent).58 Nonsteroidal anti-inflammatory drugs should be discontinued
and patients should be encouraged to stop smoking. Observational studies
have shown that patients with H. pylori colonization have a higher incidence
of marginal ulcer formation.63–65 Furthermore, in one study, preoperative test-
ing and treatment of H. pylori significantly reduced the incidence of
postoperative marginal ulcers (2.4 versus 6.8 per cent in unscreened
patients).65 Therefore, preoperative H. pylori screening should continue,
especially in geographically high-prevalence areas.66
Surgical treatment for marginal ulcers is indicated if persistent pain or
recurrent bleeding occurs, despite maximal medical management. Surgical
revision is rarely required.58 Truncal vagotomy at the time of revision has
been described.67 Post operative proton pump inhibitors should be given
empirically in high risk groups and a zero tolerance policy towards NSAIDs
in gastric bypass patients.
Cholelithiasis
Without prophylaxis, cholelithiasis develops in as many as 38 per cent of
patients within six months of surgery, and up to 41 per cent of such
patients become symptomatic.68 Rapid weight loss contributes to the
development of gallstones by increasing the lithogenicity of bile. Obesity
itself is also a risk factor. Some surgeons recommend performing chole-
cystectomy at the time of bypass if a patient has symptomatic gallstones
preoperatively. The surgical opinion about asymptomatic gallstones is
Roux-en-Y Gastric Bypass
177

more divided, and studies have failed to demonstrate a benefit for simul-
taneous cholecystectomy for incidental gallstones at the time of RYGB.
Further investigations in the form of randomized, prospective studies are
necessary to clearly define the indications for cholecystectomy at the time
of weight loss surgery.68
Uncommonly, patients develop choledocholithiasis (stones in the
common bile duct). Diagnosis of choledocholithiasis can be confirmed
by ultrasound or magnetic resonance cholangiopancreatography
(MRCP); however, endoscopic retrograde cholangiopancreatography
(ERCP) with cannulation of the papilla can be difficult because of the
relative inaccessibility to the duodenum due to the altered anatomy of
the Roux-en-Y configuration. Thus, patients may require laparoscopic
assisted transgastric access to the common bile duct or transhepatic per-
cutaneous access.69 Placement of a gastrostomy tube into the bypassed
stomach at the time of gastric bypass,70 with the addition of a radiopaque
marker to facilitate future percutaneous access to the gastric remnant has
been described. More recently, successful therapeutic ERCP through a
double balloon enteroscopy has been reported, obviating the need for
surgery in the majority of patients with choledocholithiasis after
RYGB.71
Ventral incisional hernia
Ventral incisional hernias occur with a frequency of 0–1.8 per cent in
laparoscopic series and as high as 24 per cent in open series, highlighting
a clear advantage of the laparoscopic approach in this regard. Many
surgeons postpone a formal repair until significant weight loss occurs
(> 1 year). Indications for early surgical repair include significant pain,
bowel obstruction and rapid enlargement of the hernia.72
Internal hernias
Laparoscopic GBP does offer distinct advantages over traditional open
surgery, such as fewer wound complication, superior cosmesis, better
visualisation and fewer post operative adhesions. Adhesions, however
are required for fixation of roux limb to prevent its displacement and to
178
B. Dillemans and S. Van Cauwenberge

close mesenteric defects that allow postoperative herniation of the
bowel and subsequent complications.73 Incidence of internal herniation
in laparoscopic gastric bypass in the literature has been reported to be
3–4.5 per cent.74 Postoperative weight loss typically occurs some
months after surgery, resulting in loss of intraperitoneal fat which, in
turn, leads to larger mesenteric defects. Internal hernias on average
present clinically on average 14 months after surgery. Paroz et al.75
noted mean loss of 14.5 BMI units between primary operation and her-
nia presentation. Patients usually present with intermittent post
prandial colicky abdominal pain and nausea. Higa et al.,76 in their series
on 2,000 consecutive patients, reported that 20 per cent of symptomatic
patients with internal hernia had completely normal contrast studies.
The location of internal hernia has been documented with transverse
colon hernias to be commonest followed by enteroenterostomy and
then Peterson’s space hernias. The use of antecolic anastomosis elimi-
nates transverse mesocolic hernia thus reducing the overall incidence
of internal hernias. Even accurate closure of all mesenteric defects does
not avoid this complication.
The antecolic approach for the Roux-limb, the division of the greater
omentum and the systematic closure of the defects with tight non
absorbable running sutures are recommended.77 A high index of suspicion
is required for patients presenting with symptoms of intermittent small
bowel obstruction, which warrants prompt non-invasive investigations
and laparoscopy if the findings of contrast studies are equivocal.
Side Effects of Roux-en-Y Gastric Bypass
Postoperative hypoglycaemia
A small number of patients develop blackouts and seizures after weight
loss surgery due to a severe form of recurrent hyperinsulinemic
hypoglycaemia.43 Pancreatic nesidioblastosis has been proposed as a
mechanism for the pathologic finding of beta islet hypertrophy in these
patients, although a few cases of insulinomas have been found.44,78
Gastric bypass-induced weight loss may unmask an underlying beta cell
defect or contribute to pathological islet hyperplasia.44
Roux-en-Y Gastric Bypass
179

A wide variety of clinical approaches have been proposed to address
severe hypoglycaemia after gastric bypass. We suggest beginning with
simpler and safer interventions:
•
Patients with symptomatic hypoglycaemia respond well to dietary
modification (low carbohydrate diet).79 Those patients that are
refractory to a low carbohydrate diet can be treated with the alpha-
glucosidase inhibitor acarbose.
•
Based on the theory that severe, disabling hypoglycaemia after gastric
bypass surgery occurs in patients with loss of gastric restriction, with
resultant rapid food passage and absorption, restoration of gastric
restriction can be therapeutic. Z’graggen et al. surgically placed a
silastic ring or an adjustable gastric band around the pouch, and in their
series resolved symptoms in 11 of 12 patients with this approach.80
•
Subtotal pancreatectomy or total pancreatectomy has been recom-
mended by some surgeons to control hypoglycaemia but should be
used as last resort.64
Dumping
Symptoms of dumping syndrome are similar to those of hypoglycaemia, but
dumping occurs early (within one hour after eating), is not associated with
hypoglycaemia and is presumed to be caused by contraction of the plasma
volume due to fluid shifts into the gastrointestinal tract. Dumping syndrome
is commonly seen in post-gastric bypass patients when high levels of sugar
and/or fat are ingested, and may contribute to weight loss in part by causing
the patient to modify his/her eating habits. Patient’s preoperative nutritional
status influenced the presence of clinical manifestations. Adequate dietary
management reduced the presence of dumping symptoms in 53 per cent of
the patients, during a short-term follow-up period.81 Monthly administration
of a long acting repeatable octreotide may also improve symptoms and
quality of life in patients with postoperative dumping.82
Nutritional deficiencies
Micronutrient and mineral deficiencies can occur after bariatric surgery,
particularly after gastric bypass, both because of inadequate intake of
180
B. Dillemans and S. Van Cauwenberge

nutrients and because of alterations in the digestive anatomy due to the
surgery.
In addition to calcium and vitamin D deficiency leading to
metabolic bone disease, gastric bypass patients also have decreased
absorption of iron, vitamin B12, fat soluble vitamins (A, D, E, K),
thiamine and folate.
After Roux-en-Y gastric bypass, the food stream bypasses most of the
stomach. This results in various alterations that can lead to vitamin B12
deficiency, and can be corrected by supplements.83 Peripheral neuropathy
resulting from chronic vitamin B12 deficiency may not be reversible, and
must be prevented by diligent laboratory monitoring and adequate
replacement.
Absorption of dietary iron is also reduced due to lower acid content in
the gastric pouch and the bypass of its main sites of absorption (the duo-
denum and proximal jejunum). Iron deficiency anaemia is more
commonly seen in menstruating women following gastric bypass.84
Prophylactic iron supplementation has been shown to lower the incidence
of iron deficiency and subsequent anaemia.85
The following supplementation is recommended:
•
Patients should receive intramuscular injections of 1,000 mcg of vita-
min B12 every three months for life or take 1,000–2,000 mcg
sublingual vitamin B12 daily. The dose may be reduced if long-term
monitoring shows elevated vitamin B12 levels.
•
Patients should take a daily multivitamin containing B vitamins and
vitamin C, fat-soluble vitamins and minerals. Some patients require a
liquid vitamin preparation because the pills are not tolerated by the
stomach pouch. Patients should be transitioned to an adult pill sup-
plement when possible.
•
Vitamin D deficiency is a concern after gastric bypass and 800 IU is
recommended daily. Most multivitamin supplements contain 400 IU
of vitamin D. Additional supplementation is recommended by taking
a second multivitamin, or ingesting a second supplement containing
calcium and vitamin D.
•
Patients should take calcium supplements that provide 1,200–1,500
mg of calcium daily. Calcium citrate may be better absorbed than
calcium carbonate after gastric bypass.
Roux-en-Y Gastric Bypass
181