Extemely obese benefit from super long--limb Roux-en-Y.
Surgeons at the Mayo Clinic, Rochester, Minn., developed and refined the very, very long-limb Roux-en-Y gastric bypass (RYGBP) to meet the needs of their large referral practice in bariatric surgery, which accepts patients who are more over-weight and have worse comorbidities than are typically seen.
The more commonly performed RYGBP operations for super obese patients--the distal gastric bypass and the biliopancreatic diversion with or without duodenal switch--both leave a relatively short Roux limb, a relatively long biliopancreatic limb, and a short (100-cm) common channel where food and digestive enzymes mix.
The proximalanatomy of the very, very long--limb RYGBP is similar to that of the distal RYGBP, but the Roux limb is much longer (typically 400-500 cm). This leaves a longer transit and greater ability to absorb water, minerals, and vitamins, said Mr. Nelson, a student at the Mayo Medical School in Rochester.
The common channel is the same 100-cm length, whereas the biliopancreatic limb is typically shorter--around 50-70 cm--than in other RYGBP procedures.
"Remember, this isn't a typical Roux-en-Y gastric bypass," he said.
Of 1,435 bariatric procedures performed at the Mayo Clinic during 19852003, 257 were performed with the very, very long--limb RYGBP. These 257 consecutive patients were 45 years old on average, and had an average body mass index (kg/[m.sup.2]) of 60, with BMIs ranging from 41 to 100. A total of 40% of patients were male. More than 90% of the operations were open.
When the investigators began their study, they sent a detailed survey to patients to gather data in addition to what had been captured at normal follow-up visits; 73% of the patients responded to the survey.
After an average of 45 months of follow-up, the patients' BMI had dropped to a mean of 37, and 82% had lost more than 50% of their excess body weight, an amount commonly considered as a marker of success in bariatric surgery.
The patients who did not lose greater than 50% of their excess body weight still lost a lot of weight, Mr. Nelson said, but many of them needed to lose hundreds of pounds to reach their ideal body weight. On average, patients lost 66% of their excess body weight.
Medical comorbidities resolved without the need for further treatment in many of the patients after the operation, including type 2 diabetes in 95% of the patients, hypertension in 65%, sleep apnea in 48%, and asthma in 30%. In the survey, 90% of the patients reported that they were satisfied with the results of the operation, and 93% said that they would recommend the procedure to others. Procedural complications included two deaths, four staple-line leaks (one required reoperation), two intra-abdominal abscesses, five wound dehiscences, 22 wound infections, and two pulmonary emboli.
About 82% of the patients reported some food intolerance; and 70% had occasional loose or watery stools. The more serious complication of malnutrition resulting from protein or caloric deficiency developed in 4%; this was resolved with a proximal relocation of the jejunoileostomy to lengthen the common channel to 200-300 cm. Other problems included oxalate nephrolithiasis in 16% of the patients, and gross steatorrhea in 5%.
"Because of the potential metabolic sequelae, [the very, very long-limb RYGBP] should not be offered" to patients who are medically naive, noncompliant, or unreliable regarding follow-up, or to those who have extremely abnormal preoperative amounts of urinary oxalate, Mr. Nelson said.
Snapshot of a Very, Very Long--Limb RYGBP
The procedure leaves a Roux limb that is about three times longer than that of the standard RYGBP. The result is a longer transit and greater ability to absorb water, minerals, and vitamins.
BY JEFF EVANS
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|Publication:||Family Practice News|
|Date:||Aug 15, 2006|
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