GASTRIC BYPASS (ROUX EN Y)
A gastric bypass, specifically the Roux-en-Y procedure, is a type of weight-loss (bariatric) surgery. It is usually performed when diet and exercise haven't worked or when you have serious health problems because of your weight.
This procedure alters the way your small intestine and stomach handle the food you eat. After the surgery, your stomach will be smaller. You'll feel full with less food. Also, the food you eat won't go to some parts of your stomach and small intestine, which absorbs nutrients.
Procedure
-
Creation of a small pouch in the stomach: The surgeon uses a laparoscope (a long, thin tube with a high-intensity light and a high-resolution camera at the front) to make several small incisions in the abdomen. They then cut across the top of your stomach, sealing it off from the rest of your stomach.
-
Bypass: The surgeon then cuts the small intestine and sews part of it directly onto the small stomach pouch. Food then goes into this small pouch of stomach and then directly into the small intestine sewn to it.
-
Reconnecting the intestine: The surgeon connects the rest of the stomach to the lower part of the small intestine. This bypasses the majority of the stomach and the first section of the small intestine (duodenum), so that the second part (jejunum) can still absorb some nutrients from food.
Anesthetic Implications for Gastric Bypass
Anesthesia type: General
Airway: Endotracheal tube
Preoperative:
-
Most painful bariatric procedure
-
Assess for difficult airway
-
Consider video laryngoscopy
-
Difficult or failed intubation is more common in obese patient
-
OSA can be associated with pulmonary hypertension
-
Obesity affects every organ system
-
Patients with centralized obesity tend to have less favorable airway anatomy
-
Special attention is needed in obese patients regarding airway and cardiorespiratory status
-
Protect pressure areas because pressure sores and neural injuries are common in obese patients
-
Tracheal intubation should be performed in all patients undergoing laparoscopic bariatric surgery
Intraoperative:
-
Multimodal analgesic technique
-
Most anesthetic medications are highly lipophilic
-
The supine position is not well tolerated by a morbidly obese patient
-
Atelectasis is common after induction of anesthesia of morbidly obese
-
The reverse Trendelenburg position maximizes oxygenation because it increases functional residual capacity (FRC)
-
Duration: 1-3 hours
-
Position: Supine and reverse Trendelenburg, arms abducted
-
Bougie is used to size the pouch (enable the surgeon to delineate the anatomy to separate and anastomose the stomach)
-
Methylene blue might be used to check for leaks
-
Body habitus and a pneumoperitoneum can result in high peak airway pressures
-
Tidal volume 6–8 ml kg−1 based on IBW, and a sufficient level of PEEP should be applied (5–10 cmH2O)
Postoperative:
-
Obese patients are at higher risk for postoperative complications
-
TAP block for pain management
-
Optimal analgesia
-
Wound care
-
Deep vein thrombosis prophylaxis
-
Fluid management
-
Patients with obesity were at high risk of airway obstruction, hypoventilation and regurgitation at extubation
-
Neuromuscular block must be reversed fully at the end of surgery before extubation
Complications:
-
Bleeding
-
Nausea and vomiting
-
Thromboembolic events
-
Aspiration
-
Postoperative wound infection
-
Risk of anastomotic leaks
-
Longer-term vitamin and mineral deficiencies
Sources:
Macksey, L. F. (2011). Surgical procedures and anesthetic implications: A handbook for nurse anesthesia practice.
Jaffe, R. A. (2020). Anesthesiologist's Manual of Surgical Procedures (6th ed.).
Singh-Radcliff, N. (2013). 5-Minute Anesthesia Consult.
Soleimanpour H, Safari S, Sanaie S, Nazari M, Alavian SM. Anesthetic Considerations in Patients Undergoing Bariatric Surgery: A Review Article. Anesth Pain Med. 2017 Jul 11;7(4):e57568. doi: 10.5812/aapm.57568. PMID: 29430407; PMCID: PMC5797674.