Roux-en-y procedure

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Roux-en-y procedure

• Ri ???
• 2007/9/24

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Indication

• for preventing persistent vomiting in 1893
• Bariatric surgery
• Drainage of
• fistula/cyst

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Small proximal gastric pouch
Gastric pouch constructed of cardia to prevent
dilation and minimize acid production
Roux limb at least 75 cm in length
Enteroenterostomy constructed to avoid stenosis
or obstruction
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Characteristics

• intrinsic aboral peristaltic propulsive action ?
  conductive, not a capacitance, tube
• unidirectional aboral peristaltic action offers
  the property of a one-way valve ? reflux is
  prevented.
• ?exploited to allow esophagojejunal anastomosis
  and drainage of the biliary and pancreatie ducts.
  
• ?valuable means of draining cysts and fistulas.

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• jejunum transected and straightened, it can be
  extended to a greater distance from its vascular
  anchorage
• the rapid clearance of the jejunal segment
  ensures that there is little absorption within it

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Complications

• Wound infection
• Intra-abdominal abscess
• Leak/ Bleeding/ Stenosis
• Internal hernia
• Pulmonary embolism

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• Anemia, metabolic bone disease, nutritional
  deficiencies (iron, calcium, vitamin B12 and
  folate),
• Gastric ulcer can occur in 3 of the cases, but
  can be cured most often by drugs.
• Stenosis of the anastomosis occurs in 5 to 7 of
  the cases, with vomiting, and can be cured by
  endoscopic dilatation.
• Biliary tract stone
• Late small bowel obstruction due to adhesions or
  an internal hernia

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Postgastrectomy Syndrome

• Afferent and efferent loop syndrome
• Dumping syndrome
• Alkaline reflux gastritis
• Nutritional disturbance
• Retained antrum syndrome
• Marginal ulcer
• Postvagotomy diarrhea
• Postvagotomy atony
• Incomplete vagal transection

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Early dumping syndrome

• intake of highly concentrated substances too
  quickly before they are digested
• ?concentrated highly osmolar substances travel
  the shortened distance to the lower intestine
  quickly
• ?fluid shift into the small intestine
• ?release of serotonin, bradykinin-like
  substances, neurotensin, and enteroglucagon
• ?cramping, tachycardia, diaphoresis, vomiting,
  or diarrhea in the early dumping phase (2030mins)

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• long-acting octreotide for prevention of sym.,
  vasomotor and gastrointestinal
• ??gastric emptying / ?fasting or interdigestive
  small bowel motility pattern
• ?prolongation of intestinal transit of the
  ingested meal

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Late dumping syndrome

• ?absorbing simple sugars in small bowel
• ?a rapid glucose spike in the blood
• ?triggering insulin overshooting
• ?hypoglycemia
• ?catecholamines release resulting in
• diaphoresis, tremulousness,
• lightheadedness, tachycardia, and
• confusion in late dumping phase (23hrs)

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• Ingest frequent small meals and reduce their
  carbohydrate intake
• Use of an antiperistaltic loop of jejunum between
  the residual gastric pouch and intestine

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Alkaline reflux gastritis

• severe epigastric abdominal pain accompanied by
  bilious vomiting and weight loss
• not relieved by food or antacids
• vomiting may occur anytime during the day or
  night
• no clear correlation between the volume of bile
  or its composition and the subsequent development
  of alkaline reflux gastritis.
• No effective medical treatment

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Nutritional disturbance

• J CLin Endocrinol Metab 91 4223-4231,2006

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Glucose-dependent insulinotropic peptide
cholecystokinin
satiety-inducing hormones GLP-1 and PYY
Med Clin N Am 91 (2007) 499514
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Calcium/vit.D deficiency 10/51

• Defective absorption of fat-solubale vit. because
  of fat malabsorption? steatorrhea
• Fat malabsorption is due to the short common
  channel and delayed mixing of fat with pancreatic
  enzymes and bile salts as a result of bypassing
  the duodenum.
• bypassing the duodenum and proximal jejunum
• further aggravated as fatty acids bind calcium
• ?markers of bone turnover and/or?bone mass
• Metabolic bone disease (osteoporosis/osteomalacia)
  
• calcium carbonate(gastric acid) v.s. calcium
  citrate

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Iron-deficiency anemia 52

• malabsorption due to bypassing of the duodenum
  and proximal jejunum, the main sites for iron
  absorption
• intolerance to iron-rich foods, especially red
  meat
• reduced stomach production of hydrochloric acid
  required to reduce ferric iron to the ferrous
  state before it can be absorbed.

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/Low pH
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B12 deficiency 64

• lower portion of the stomach is removed or
  partitioned off, chief and parietal cells are
  lost that secrete hydrochloric acid and intrinsic
  factor.
• pancreatic enzymes as B12 binder proteins are
  lost as the upper portion of the small intestine
• B12 absorption in the distal ileum is
  calcium-dependent
• ?B12 prophylactic supplementation with parenteral
  ,sublingual or intranasal preparations

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Folate deficiency 38

• Primary reason for folate deficiency is decreased
  folate intake.
• Malabsorption may not play a big role,
• ? because absorption can occur along the entire
  part of the small intestine with adaptation after
  surgery
• ?prevent megaloblastic anemia

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Protein malnourishment

• small pouch size ?extremely diminished amount of
  calorie intake
• bulk of digestion occurs in the small intestine/
  loss of gastric/pancreatic enzymes? animal
  proteins more difficult for bypass patients to
  digest and absorb.
• ? Muscle catabolism and wasting

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Gallbladder stone

• weight reduction with low-calorie diet, incidence
  of gallstones increases
• mechanism not completely understood,
• ?increased saturation of bile and stasis
• ?increased gall-bladder secretion of mucin and
  calcium
• ?increased presence of prostaglandins and
  arachidonic acid
• Ursodeoxycholic acid administered effective in
  preventing gallstone formation

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Thanks !