Length of roux

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Length of roux

  1. 1. Gastric Bypass: Does Length of Roux Limb Matter?<br />Samer G. Mattar, MD, FRCS, FACS<br />Associate Professor of Surgery<br />Indiana University<br />
  2. 2. Outline <br />Incidence of Revisional and Reoperative Bariatric Surgery<br />Causes of failed primary operations<br />Evaluation of the patient with failed primary operation<br />Role of Roux limb length.<br />Outcomes<br />
  3. 3. Gastric Bypass“A family of operations”<br />Hand-sewn versus stapled GJ anastomosis<br />Linear versus Circular stapling mechanisms<br />Closure versus non-closure of potential internal hernia sites<br />Closure versus non-closure of larger trocar sites<br />
  4. 4. Gastric Bypass“A family of operations”<br />According to Dr. Pories, the potential number of gastric bypasses is 29, or at least 512 different operations.<br />
  5. 5. Growth of Bariatric Surgery: 500%<br />NEJM 350;11, 2004, March 11, 1075-1079<br />
  6. 6. Bariatric Surgery Increase<br />Total number of Roux-en-Y Gastric<br /> Bypasses Performed in the USA*<br />*National Center for Health Statistics<br />
  7. 7. Bariatric Surgery Increase<br />
  8. 8. Incidence of Revisional Bariatric Surgery<br />Hard to predict.<br />Upwards of 25% of bariatric patients will undergo a revisional procedure<br />Gagner M, Gentileschi P, de Csepel J, et al. Laparoscopic reoperative bariatric surgery : experience from 27 consecutive patients. Obes Surg 2002; 12:254-260<br />
  9. 9. Incidence of Revisional Bariatric Surgery<br />
  10. 10. Definition of Failed Bariatric Surgery<br />Weight loss < 50% EWL<br />Regain of > 15% of weight after reaching nadir<br />Inadequate resolution or improvement of co-morbidities<br />
  11. 11. Causes of Failed Bariatric Surgery<br />Inability to adapt to specific lifestyle.<br />Inability to maintain lifestyle changes.<br />Treatment with medications that increase appetite.<br />Anatomic factors (eg large pouch)<br />Lack of follow up.<br />
  12. 12. Evaluation of the failed patient<br />Careful detailed history by physician, dietitian, and psychologist.<br />Review stressful factors, medications.<br />Food journal.<br />Close and frequent counseling.<br />Back on Track program.<br />Support groups<br />
  13. 13. Evaluation of the failed patient<br />Upper GI endoscopy to assess pouch size, anatomy, staple line breakdown.<br />Upper GI films to assess pouch size, band position, esophageal dilatation, hiatus hernia, etc.<br />These studies are essential for planning revisional surgery.<br />Review operative notes (if available).<br />
  14. 14. Who should not be converted?<br />Substance users.<br />Patients with GERD who have not had medical therapy.<br />Patients with maladaptive eating who fail to comply, in spite of normal anatomy.<br />
  15. 15. The Failed Patient with Normal Anatomy<br />Clinical Dilemma.<br />Limited options.<br />
  16. 16. Variations “Lengthening the Roux”<br />Rationale:<br />The more distal the Roux, the more profound the weight loss.<br />
  17. 17. Variations “Lengthening the Roux”<br />Brolin in 1992:<br />Prospective randomized study compared weight loss in patients with Roux length of 75cm to patients with Roux of 150cm<br />Concluded that patients with longer Roux lost more weight at 2-3 years.<br />No significant difference in nutritional changes.<br />Brolin et al. Ann Surg 1992:215: 387<br />
  18. 18. Variations “Lengthening the Roux”<br />Distal RYGB<br />Occasionally done for super obese patients<br />Occasionally done for patients with weight regain and normal pouches.<br />
  19. 19. Variations “Lengthening the Roux”<br />Distal RYGB<br />Nutritional issues<br />Essentially a malabsorptive operation<br />Danger for protein calorie malnutriton<br />Fat soluble vitamin deficiencies<br />Diarrhea<br />High incidence of anemia<br />
  20. 20. Variations “Lengthening the Roux”<br />Sugerman in 1997:<br />Compared standard Roux length with distal (common channel only 50 cm long)<br />Distal group had more weight loss. <br />But, > 50% serious complications, including 2 liver deaths. <br />Sugerman et al J Gastrointest Surg 1997;1:517<br />
  21. 21. Variations “Lengthening the Roux”<br />Brolin in 2002:<br />Compared patients with standard RYGB to patients with distal RYGB (75 cm from cecum).<br />Distal Gastric Bypass produced better weight loss.<br />But, had significantly greater metabolic problems<br />Brolin et al J Gastrointest Surg 2002;6:201<br />
  22. 22. Modifying Roux-limb length<br /><ul><li>Short Roux-limb: 75cm
  23. 23. Long Roux-limb: 150 cm
  24. 24. Distal Bypass: 75 cm common channel</li></ul>Brolin et al. J Gastrointest Surg 2002;6:195-205<br />Distal Gastric Bypass<br />
  25. 25. BMI Change According to Roux-limb Length<br />Brolin et al. J Gastrointest Surg 2002;6:195-205<br />
  26. 26. RYGB Malabsorption<br />Distal RYGB reserved for failed patients with intact anatomy.<br />The Bilio-pancreatic limb is anastomosed 50-75 cm from ileo-cecal valve<br />EWL% = >50%<br />
  27. 27. RYGB Malabsorption<br />But <br />Complications include:<br />Fat soluble vitamin deficiency<br />Liver dysfunction<br />Normocytic normochromic anemia<br />Protein calorie malnutrition<br />
  28. 28. Comparison study of Standard vs. Long Roux in Superobese<br />120 patients (all BMI > 50)<br />65 had SLL (50 + 150)<br />55 had LLL (50 + 200)<br />There was no significant difference in weight loss.<br />Sarhan et al. ObesSurg Online first April 15th, 2011<br />
  29. 29. Conclusions<br />There are many variations of gastric bypass.<br />The length of Roux limb between 150 – 200 cms. will not significantly impact weight loss.<br />Distal RYGB (50 – 75cc from IC) will cause significant weight loss but will increase risk of nutritional deficiencies.<br />
  30. 30. Thank you!<br />

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