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Home , Billroth I, Gastric bypass surgery

ARTICLE IN PRESS

International Journal of Open ■■ (2016) ■■–■■

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International Journal of Surgery Open

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1 Review Article 2 3 Overview of 4 5 Q1 Elroy Patrick Weledji *

6 Department of Surgery, Faculty of Health Sciences, University of Buea, Cameroon 7 8 9 ARTICLE INFO ABSTRACT 10 1211 Article history: Gastric bypass surgery is indicated for several clinical reasons including benign and malignant upper gas- 1413 Received 7 June 2016 trointestinal tract pathologies. Any gastric resection or bypass procedure interferes with gastric emptying 1615 Received in revised form 17 September and the aim of reconstruction is to minimize the disturbance to the upper gastrointestinal physiology. 17 2016 18 Gastric bypass procedures induce early satiety, with or without concomitant impaired absorption of nu- 19 Accepted 19 September 2016 20 trients, and offer the best solution for morbid . The long-term health benefits of gastric bypass 21 Available online 22 surgery for morbid obesity must be found to outweigh the operative risks and side-effects of gastric bypass 23 24 and thus patient selection is fundamental. The aim of the study was to review the indications, compli- 25 Keywords: 2726 Gastric bypass cations, sequelae and outcome of gastric bypass procedures. 2928 Indications © 2016 Published by Elsevier Ltd on behalf of Surgical Associates Ltd. This is an open access article 3130 Complications under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). 32 Sequelae 33 34 1. Introduction 2. Gastrojejunostomy 65 35 66 36 The history of gastric bypass surgery began in 1880 when the By diverting away from the , anastomo- 67 37 Polish surgeon Ludwik Rydygier performed a for sis of the to a loop of was once used to treat 68 38 peptic ulcer disease [1]. In 1885, the Austrian surgeon Theodor duodenal ulcer but carried a high recurrence (50%) rate [12]. Gas- 69 39 Billroth (Fig. 1) performed a first-stage gastrojejunostomy to alle- trojejunostomy was then used as a drainage procedure following 70 40 viate the symptoms of an obstructing large pyloric tumour followed truncal for peptic ulcer disease but has fallen into disuse 71 41 by a second-stage resection of the tumour with restoration of gas- since the advent of effective medical treatment to suppress gastric 72 42 troduodenal continuity [1,2]. Most modern forms of with acid output and antral invasion [13,14]. Lapa- 73 43 gastrojejunal (Billroth II) are modelled on this oper- roscopic gastrojejunostomy (LGJ) has been proposed as the technique 74 44 ation and described for the treatment of peptic ulcer disease in 1911 preferred over open gastrojejunostomy for relieving gastric outlet 75 45 [2–4]. With the success of antral Helicobacter pylori eradication triple obstruction (GOO) due to malignant and benign disease with im- 76 46 therapy for peptic ulcer disease which includes antibiotics and a re- proved outcome and an acceptable complication rate [15]. 77

47 versible chemical vagotomy with H2 receptor antagonist or proton Gastrojejunostomy would also bypass congenital pre-ampullary du- 78 48 pump inhibitor, surgery is now indicated only for the emergency odenal obstruction from a duodenal web/atresia/stenosis and an 79 49 complications of perforation, severe vomiting from pyloric steno- annular , with no or minimal early or long term compli- 80 50 sis and haemorrhage [5]. It was also well recognized that Billroth cations including [16]. Although resection of a primary 81 51 II (partial) gastrectomy is associated with and several gastric tumour provides better palliation than bypass surgery pro- 82 52 variations of this procedure have been used effectively in the sur- vided the patient’s general health will allow this, patients with 83 53 gical treatment of morbid obesity with benefit lasting for up to 10 unresectable distal gastric tumours may benefit from a high antecolic 84 54 years [4,6–11]. The restriction of volume of ingested food togeth- gastrojejunostomy [17–19]. The control of the rate of delivery of the 85 55 er with altered absorption of nutrients, especially fat contributes gastric contents to the that allows adequate mixing 86 56 to achieving the weight loss and the malabsorptive procedures alter with bile and pancreatic juices and avoids overwhelming the di- 87 57 the digestive process in different ways [8–11]. The aim of this review gestive and absorptive capacity of the small intestine requires an 88 58 was to evaluate the common gastric bypass procedures with regard intact and innervated . The importance of attempting to pre- 89 59 to their indications, sequelae and outcome. serve normal gastric emptying in gastric bypass procedures without 90 compromising oncological results is seen with the more physio- 91 60 logical post-operative digestive function of the pylorus – preserving 92 partial for pancreatic head cancer than 93 61 with the partial stomach resection of the classical Kausch–Whipple 94 62 Q2 * Department of Surgery, Faculty of Health Sciences, University of Buea, PO Box 126, 63 Limbe, S. W. Region, Cameroon. procedure [20]. The Whipple’s procedure is also occasionally indi- 95 64 E-mail address: [email protected]. cated in cases of duodenal or pancreatic head trauma. Following a 96

http://dx.doi.org/10.1016/j.ijso.2016.09.004 2405-8572/© 2016 Published by Elsevier Ltd on behalf of Surgical Associates Ltd. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Please cite this article in press as: Elroy Patrick Weledji, Overview of gastric bypass surgery, International Journal of Surgery Open (2016), doi: 10.1016/j.ijso.2016.09.004 ARTICLE IN PRESS

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tomy) (Fig. 1) [2–4]. The Polya gastrectomy with retrocolic end-to- 145 side gastrojejunostomy has become a commonly performed 146 modification of the Billroth II procedure [2]. Franz von Hofmeister 147 described a partial gastrectomy with a retrocolic gastrojejunos- 148 tomy involving the greater curvature [2,28]. Reconstruction following 149 partial gastrectomy may be simple or difficult depending partly on 150 the build of the patient and partly on the extent and nature of the 151 disease process. Thus Billroth II gastrectomy is usually used for an 152 emergency perforated large duodenal ulcer not suitable for simple 153 omental patch closure and when a duodenal anastomosis (Billroth 154 1) cannot easily be made [29]. A gastrectomy is not a bypass 155 procedure and is suitable for a resistant benign gastric ulcer after 156 excluding malignancy [14,27]. The Billroth II is associated with prob- 157 lems of bile reflux into the gastric remnant and oesophagus, and a 158 higher risk of stomal ulceration. Thus, approximately two-thirds of 159 stomach should be resected to avoid repeated antral exposure to 160 bile [6,14]. For the theoretical benefits of delaying gastric emptying 161 97Q10 Q13 Fig. 1. Diagram of Billroth II gastrectomy. and preventing reflux of duodenal contents into the stomach, a 162 98 Hofmeister ‘valve’ can often be fashioned by reducing the stoma length 163 to around 5 cm through closing part of the opening in the gastric 164 99 retroperitoneal duodenal injury, options for duodenal repair may stump and the rest being used for the actual anastomosis [28]. 165 100 include a pyloric exclusion effected through a . The pyloric 166 101 ring is closed with a continuous suture or stapling which breaks down 3.1. Complications 167 102 after several weeks. The procedure is combined with a gastrojeju- 168 103 nostomy and the addition of octreotide and intravenous acid Billroth II gastrectomy was favoured for many years for its rel- 169 104 suppression may improve duodenal healing and decrease stomach atively low peptic ulcer recurrence rate (less than 5%) [2,4,6]. 170 105 ulceration. Roux-en-Y loop (Roux-en-Y duodenojejunostomy) drain- However, it has a high mortality and complication rate [6,14]. Leakage 171 106 age of the defect from significant tissue loss in the second part of may occur from either the duodenal stump or from the anastomo- 172 107 the duodenum is the procedure of choice in the stable patient [21]. sis. Leakage from the duodenal stump is usually due to afferent loop 173 108 Both the duodenum and the are triply bypassed with a obstruction. This risk is reduced by the formation of a Roux-en-Y 174 109 gastroenterostomy, and a retrocolic Roux-en-Y hepatico- reconstruction. If there is controlled leak without or gener- 175 110 for a duodenal obstructive, locally-advanced pancreatic head car- alized conservative treatment is indicated with parenteral 176 111 cinoma [22]. However a prophylactic gastrojejunostomy may suffice nutrition. Otherwise exploration is required to drain any sepsis and 177 112 for an obstructive unresectable periampullary carcinoma [23]. to establish drainage of the afferent loop. A useful technique for the 178 113 latter is to insert a T tube into the duodenum and, therefore, es- 179 114 2.1. Complications tablish a controlled fistula, and to decompress the afferent loo 180 115 obstruction [6,30,31]. It is unlikely that direct suture of a leak will 181 116 Early technical complications from a gastrojejunostomy would be feasible. Treatment of a gastrojejunal leak is problematic. More 182 117 include: (a) haemorrhage which is usually from the gastric side of commonly the leak is delayed, occurring 7–14 days postopera- 183 118 the anastomosis and usually only starts when the clamps are re- tively. If there are clinical features to indicate that this is limited 184 119 leased, by which time the lumen is not visible. It occasionally requires and localized, then conservative treatment with nutritional support, 185 120 exploration; (b) leakage may occur as a result of tension on the anas- gastrointestinal decompression and antibiotics is indicated .Other- 186 121 tomosis. Difficulty in bringing the stomach and jejunum together wise, reoperation is required. 187 122 without tension may require opening the gastrocolic omentum and 188 123 performing a retrocolic posterior gastroenterostomy. Otherwise, there 3.2. Side effects and post-prandial sequelae 189 124 is little advantage over the simple antecolic gastroenterostomy 190 125 [24,25]; (c) an internal if the mesenteric defects are not closed; 3.2.1. Early satiety 191 126 (d) sepsis, either as a wound infection or an intraabdominal ; Early satiety arises from the loss of reservoir function of the 192 127 (e) early obstruction follows oedema around the stoma or kinking, stomach and it is important to obtain good early dietary advice and 193 128 or, later due to progression of malignancy especially if done for pal- limit meal size. The excision of 80% of the stomach leads to reduced 194 129 liation. Late complications include stomal ulceration which can be gastric volume resulting in early satiety and hence weight loss. 195 130 prevented by proton pump inhibition and pancreatitis due to af- Gastric bypass surgery not only reduces the gut’s capacity for food 196 131 ferent loop obstruction [6,24]. but also dramatically lowers levels compared to both lean 197 132 controls and those that lost weight through dieting alone [32,33]. 198 133 3. Billroth II gastrectomy Ghrelin, the “hunger hormone”, is a peptide hormone produced by 199 134 ghrelinergic cells in the which functions as a 200 135 The Billroth II gastrectomy is often indicated for refractory peptic neuropeptide in the central nervous system. Besides regulating ap- 201 136 ulcer disease and gastric adenocarcinoma [14,26,27]. Except in the petite, ghrelin also plays a significant role in regulating the 202 137 aged, most surgeons now opt for a partial gastrectomy to treat a distribution and rate of use of energy [34]. It prepares the body for 203 138 resistant peptic ulcer after excluding acid hypersecretion from a pan- food intake by acting on hypothalamic brain cells to increase hunger, 204 139 creatic islet cell gastrinoma [14,26]. Following resection of the distal gastric acid secretion and gastrointestinal motility [35,36]. Ghrelin 205 140 stomach, reconstruction can be performed by either fashioning a is secreted when the stomach is empty, but secretion stops when 206 141 new lesser curve and creating an end-to-end gastroduodenal anas- the stomach is stretched. Bariatric involving excision of 207 142 tomosis (Billroth I gastrectomy) described in 1881, or, by an end- the fundus as in vertical reduce plasma ghrelin 208 143 to-side anastomosis of the gastric remnant to a loop of jejunum, levels by about 60% in the long term [37]. However, studies are con- 209 144 with closure of the duodenal stump (Billroth II or Polya gastrec- flicting as to whether or not ghrelin levels return to nearly normal 210

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211 with gastric bypass patients in the long term after weight loss has lowing a meal (late dumping). Dietetic input is crucial and involves 277 212 stabilized [38]. reducing amount of carbohydrate in main meals with regular glucose 278 213 in-between (glucose tablets) [6,39,42]. 279 214 3.3. Post-prandial sequelae 280 215 3.3.3. Diarrhoea 281 216 There is a distressing array of new gastrointestinal symptoms Diarrhoea is caused by truncal or inevitable vagotomy, early 282 217 (‘post gastrectomy syndrome’) resulting from the loss of reservoir dumping, and bacterial overgrowth [39,41,42]. The combination of 283 218 function, denervation, disruption of the pyloric mechanism and the loss of gastric acid and formation of blind loops results in accumu- 284 219 type of reconstruction. Post gastrectomy syndromes include lation of aerobic and anaerobic organisms normally found in colon. 285 220 metabolic/nutritional alterations, , bile reflux gas- Faecal bacteria release toxins that destroy brush borders vital to di- 286 221 tritis, gastroparesis, afferent/efferent limb syndromes, the Roux gestion and consume B vitamins. They deconjugate bile acids 287 222 syndrome and postvagotomy diarrhoea. About 25% of patients will essential for normal fat absorption in the proximal small intes- 288 223 develop post gastrectomy syndrome but only 1–4% develop severe tine. The increased faecal fats result in steatorrhoea and weight loss. 289 224 debilitating symptoms. It is made worse by bad technique. Too ex- Investigation involves 14C glycocholate breath test and treatment in- 290 225 tensive a resection predisposes to a high incidence of postprandial cludes the antibiotics (metronidazole/neomycin) and (fresh 291 226 symptoms including early dumping that severely limits calorie intake unpasteurized yoghurt) to inhibit recolonization with and after an- 292 227 [14,39]. tibiotics. Relative pancreatic insufficiency may also result in 293 228 steatorrhoea but once bacterial overgrowth is excluded, it can be 294 229 3.3.1. Early dumping treated with pancreatic enzyme supplementation (Creon). Post va- 295 230 Post gastrectomy complications may occur as vasomotor gotomy diarrhoea is due to vagal denervation leading to intestinal 296 231 ‘dumping’ due to rapid gastric evacuation from loss of pyloric reg- dysmotility, rapid gastric emptying of liquids, hypoacidity, malab- 297 232 ulation and receptive relaxation resulting in a hypertonic load to sorption of bile acids and bacterial overgrowth in the proximal bowel. 298 233 the small intestine triggering autonomic reflexes and release of va- Severe form of post vagotomy diarrhoea may have 10–20 epi- 299 234 soactive peptides. Fluid shifts can cause hypotension triggering sodes per day, often explosive with no temporal relationship with 300 235 autonomic catecholamine surge. Multiple gut hormones impli- food and occurring at all times even during sleep. It is associated 301 236 cated include serotonin, vasoactive intestinal peptide (VIP), with malnutrition, weight loss, and weakness [6,42].1%ofpostva- 302 237 (CCK), neurotensin, peptide YY, enteroglucagon etc. gotomy diarrhoea are refractory to medical treatment (dietary 303 238 The rapid filling of proximal small intestine with hypertonic food modifications, bile chelator (cholestyramine), oral neomycin, 304 239 also leads to rapid movement of fluid into the gut from extracel- antidiarrhoeal agents) and severe enough for surgical interven- 305 240 lular space resulting in diarrhoea. The characteristic symptoms of tion. The antiperistaltic jejunal interposition 75–100 cm from the 306 241 early dumping are epigastric fullness, sweating, faintness and pal- ligament of Treitz or the Cuschieri reversed distal ileal onlay graft 307 242 pitations 30 min after eating and may last for an hour. These can gives relief for the majority [43], 308 243 lead to food avoidance with reduced quality of life and malnutri- 309 244 tion. It is more troublesome following subtotal gastrectomy or where 3.3.4. Bilious vomiting 310 245 pylorus is destroyed or bypassed. Dumping symptoms are quite Bile reflux gastritis is more common after Billroth II gastrec- 311 246 common in the first weeks or months but improve over the months tomy and less with Roux-en-Y procedure. It commonly occurs after 312 247 from small bowel adaptation or unconscious modification of diet gastric reconstruction with debilitating symptoms in 1–2%. The symp- 313 248 [40,41]. 1–2% have debilitating symptoms but because of genuine toms of alkaline bile reflux are epigastric discomfort, heartburn, and 314 249 reassurance to the patient, dietary advice to eat small meals, re- vomiting. Persistent reflux can lead to stricturing and dysphagia 315 250 strict carbohydrate intake and avoid too much fluid less than 1% [43,44]. It would be diagnosed by upper gastrointestinal endosco- 316 251 requires surgical intervention. In many patients there is develop- py and Tech 99M HIDA scanning. Gastric emptying study would rule 317 252 ment of malnutrition, manifested as anaemia and weight; loss in out gastroparesis [44,45]. Medical management with PPIs and H2 318 253 the first few months after operation to a new level which then stays blockers is rarely helpful thus requiring revisional surgery. Biliary 319 254 steady [14,41]. diversion is used most often for severe bilious vomiting or if symp- 320 255 As many of the postgastrectomy problems are due to by-pass of toms are unremitting as treatment options are limited and only often 321 256 the duodenum and loss of gastric capacity, dumping may be di- successful. A simple version is jejuno-jejunostomy between the af- 322 257 minished by conversion to a Billroth I anastomosis, a Roux-en-Y ferent and efferent limbs of a gastrojejunostomy (Uddin loop) where 323 258 reconstruction or by interposing a 10–15 cm segment of proximal the former is quite long. An alternative common variety is a sub- 324 259 jejunum aimed at slowing down gastric emptying [14,27]. Unfor- total (80%) gastrectomy with Roux-en-Y reconstruction with the 325 260 tunately, the use of gastric pouches or jejunal interpositions has not efferent loop some 40–50 cm distal to the stoma or lengthening of 326 261 significantly improved on the results of more standard reconstruc- Roux loop which gives 80% relief [46]. Again proton pump inhibi- 327 262 tions. A particular hazard of jejunal interposition is an increased risk tion would reduce the risk of gastrojejunal ulceration [14]. 328 263 of bile and alkaline reflux with consequent peptic ulceration at the Gastro-oesophageal reflux disease (GORD) is more prevalent as 329 264 new gastrojejunal junction. The defect of normal peristalsis in the (BMI) increases. There is reduced long-term ef- 330 265 long jejunal limb may also result in voluntary and involuntary re- fectiveness of anti-reflux () procedure in obese 331 266 gurgitation. And so this operation should only be used in those with patients (BMI >30). Laparoscopic Roux-en-Y gastric bypass is the most 332 267 severe degree of dumping or small stomach syndrome and a proton effective and recommended option as it treats GORD, reduces weight, 333 268 pump inhibitor (PPI) given. The beneficial effect of the Roux-en-Y and improves [47]. Likewise, bile reflux following 334 269 is thought to be due to transection of the neural plexuses that ef- gastric bypass for morbid obesity will benefit from the very effec- 335 270 fectively slow gastric emptying in the long jejunal limb [41]. tive and much simpler anti-reflux (laparoscopic Nissen 336 271 fundoplication) procedure than revision surgery [48]. 337 272 3.3.2. Reactive hypoglycaemic attacks Gastroparesis is delayed gastric emptying in the absence of me- 338 273 Complex neurohumoral response produces unpleasant gastro- chanical obstruction. It is the most common (50%) of the post 339 274 intestinal and cardiovascular symptoms. Rapid carbohydrate gastrectomy syndromes especially with associated truncal va- 340 275 absorption stimulates excessive or asynchronous secretion gotomy, and, generally inversely proportional to the extent of gastric 341 276 causing a rebound hypoglycaemia, blackouts, and seizures 2–3 h fol- resection [49,50]. The patient is unable to tolerate diet 7–14 days 342

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343 after surgery but the vast majority improves with time or with growth in the jejunum. The effects are complex, but malabsorption 409

344 Q3 prokinetic agents. Other causes metabolic (electrolyte, endocrine, of fat, vitamin B12 and other B vitamins is usually present. A course 410 345 medications), mechanical (stoma oedema, small leaks, adhesions, of broad-spectrum antibiotics will usually temporarily restore 411

346 kinking, haematoma, intussusception, stricture) should be ruled out. vitamin B12 absorption to normal, but complete cure may require 412 347 Sometimes surgery is required with the original operation dictat- revisional surgery [6,14,53]. Patients should be supplemented with 413 348 ing the corrective procedure, i.e. further resection following a partial vitamin B during and after treatment. malabsorption 414 349 resection. Most advocate R-Y reconstruction and completion va- results in osteomalacia especially in post-menopausal women. Thus 415 350 gotomy [51] . all patients >70 years would receive calcium supplements and 416 351 undergo 5-yearly assessments for metabolic bone disease. 417 352 3.3.5. Afferent/efferent loop syndromes 418 353 Afferent loop syndrome is a mechanical problem with partial ob- 4.2. Iron deficiency anaemia 419 354 struction of the afferent limb from kinking, angulation, stenosis or 420 355 adhesions. The afferent limb being almost always 30–40 cm or longer Iron deficiency anaemia is present in 40–50% of patients fol- 421 356 is a predisposing factor and always occurs with a Billroth II bypass. lowing partial gastrectomy [42]. In addition to impaired dietary 422 357 Treatment is always surgical. It entails either revision of Billroth II, intake, is associated with impaired absorption of iron 423 358 conversion of Billroth II to Billroth I, conversion of a Billroth II to in the duodenum and jejunum as reduced ferrous (Fe2) rather than 424 359 R-Y with a long Roux limb and complete vagotomy to prevent mar- food ferric (Fe3) ion is absorbable. Iron malabsorption is not nor- 425 360 ginal ulcer or fashioning an entero-enterostomy below the stoma mally an issue unless vegetarian, as small intestine takes over 426 361 if adhesions are present [30]. The Chronic type is more common. absorption. Iron and vitamin C supplements should be considered 427 362 The severe post prandial pain, bile and pancreatic secretions build for the first post-operative year [42,53]. 428 363 up in the afferent limb until the intraluminal pressure overcomes 429 364 the obstruction resulting in projectile bilious vomiting with im- 5. Gastric cancer 430 365 mediate relief of pain. The efferent loop syndrome is less common 431 366 and difficult to distinguish from afferent loop syndrome or bile reflux The risk of Gastric malignancy in the remnant stomach is in- 432 367 gastritis. It is usually due to adhesions or an internal hernia of the creased about 4-fold. The exact mechanism is unclear, but 433 368 limb behind the gastrojejunal anastomosis and treatment is always achlorhydria, atrophic gastritis, persistent bile reflux, denervation 434 369 surgical. of the and bacterial invasion of the gastric stump 435 370 have been regarded as possible aetiologies [54,55]. The gastric 436 371 3.3.6. The Roux syndrome mucosa of the patients who underwent gastric surgery for malig- 437 372 The Roux syndrome is a complex of symptoms including post nancy tends to develop recurrent cancer, less than 10 years after 438 373 prandial epigastric fullness, nausea, intermittent vomiting and often surgery at the anastomosis site and new cancers at the non- 439 374 weight loss. It is thought to be the result of an atonic roux limb that anastomosis site. Those patients with initially benign disease may 440 375 impedes gastric emptying. Studies have demonstrated that it is a develop cancer but more than 10 years after at the anastomosis site 441 376 result of loss of the duodenal pacesetter potentials which are fastest [56]. By attenuating the chronic gastritis–metaplasia–dysplasia– 442 377 in the duodenum and spread distally to the terminal . The fre- carcinoma sequence, there is a role for H. pylori eradication therapy 443 378 quency is decreased when the jejunum is resected and ectopic in preventing anastomotic recurrence or a new primary [27,56]. 444 379 pacemakers spread retrogradely to the stomach. It is thus com- 445 380 moner with a large gastric remnant and after truncal vagotomy. 6. Bariatric surgical procedures that involve gastric bypass 446 381 Treatment is with a trial of prokinetic agents or aggressive gastric 447 382 resection with R-Y reconstruction [52]. Morbid obesity defined as a body mass twice ‘ideal’ (Body mass 448 383 index >39 kg/m2) has a high health risk and excess mortality [7]. 449 384 4. Nutritional problems The National Institute of health and Clinical Evaluation (NICE) guide- 450 385 lines (2006) recommend as a treatment option for 451 386 Malnutrition following gastric bypass is usually due to failure people with morbid obesity (BMI >40 kg/m2) or who have lower BMI 452 387 to ingest sufficient calories especially in total gastrectomy pa- (35 kg/m2) plus other significant disease such as type 2 mel- 453 388 tients. Malabsorption is a rare cause of malnutrition in non- litus and that could improve if they lost weight. Because 454 389 bariatric gastric bypass surgery. Carbohydrate absorption is usually of the risks, surgery is only offered when all appropriate non- 455 390 satisfactory but protein and particularly fat absorption is reduced surgical measures are unsuccessful [8]. Several variations of Billroth 456 391 resulting in weight loss. Close dietetic follow-up should ensue after II gastrectomy as a form of biliopancreatic bypass have been de- 457 392 bacterial overgrowth, early satiety, dumping, and relative pancre- scribed and not surprisingly the more complex operations are 458 393 atic insufficiency have been excluded. associated with a higher incidence of morbidity [9]. The most com- 459 394 monly performed procedure is the Roux-en-Y gastric bypass (RYGB) 460

395 4.1. Vitamin B12 deficiency and macrocytic anaemia [10]. Biliopancreatic diversion (BPD), with or without duodenal 461 396 switch (BPD-DS), is less commonly performed but is often consid- 462

397 As vitamin B12 is bound to secreted by the pari- ered in extremely obese individuals [11]. All procedures can be 463 398 etal cells in the body and fundus of the stomach and absorbed in performed laparoscopically with a lower rate of complications such 464

399 the terminal ileum, there is virtually no absorption of B12 post gas- as wound infection and incisional [57,58]. 465

400 trectomy. B12 deficiency is always seen following total gastrectomy 466 401 and in about 50% of those patients who undergo partial gastrec- 6.1. Roux-en-Y gastric bypass (RYGB) 467

402 tomy. Methyl-methionine testing is more accurate than serum B12 468

403 in the presence of proton pump inhibitor use. Vitamin B12 deficien- RYGB is a combination of both restriction and malabsorption. The 469 404 cy usually takes some years to develop because of the large body creation of a small stomach pouch leads to early satiety combined 470 405 stores of the vitamin [6,42]. All gastrectomy patients require with the bypassing of the stomach, duodenum and up to 200 cm 471 406 3-monthly hydroxocobalamin injections. The stagnant loop syn- of jejunum leading to malabsorption. Release of distal gut hor- 472 407 drome which arises as a consequence of anatomical abnormalities mones and changes in taste also have a role in the mechanism of 473 408 of the small intestine including blind loops results in bacteria over- action. Technically, the stomach is divided (stapled) into an upper 474

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475 Fig. 2. Diagram of Roux-en-Y gastric bypass.

476

477 gastric pouch, which is 15–30 ml in volume, and a lower gastric 478 remnant. The gastric pouch is anastomosed to the jejunum after it 479 has been divided some 30–75 cm distal to the ligament of Treitz; 480 this distal part is brought up as a ‘Roux-limb’. The excluded biliary 481 limb, including the gastric remnant, is connected to the bowel some 482 75–150 cm distal to the gastrojejunostomy (Fig. 2) [53]. The small 483 size of the upper gastric pouch is so reduced that it “restricts” or 484 limits the amount of food intake. It also provides satiety with smaller 485 portions of food. The lower gastric remnant no longer receives, stores, 486 and mixes food but remains secretory. The malabsorptive element Fig. 3. Omega loop mini gastric bypass. 523 487 in gastric bypass is achieved as a result of the Roux-en-Y forma- 488 tion “bypassing” the upper part of the intestine. The length of the 524 489 Roux-en-Y limb was determined by the patient’s BMI; 100 cm for plastic changes of the gastric and oesophageal mucosa. As a result, 525 490 those with a BMI of up to 48 kg/m2 and 150 cm for patients with a MGBP remains a controversial subject, particularly as only one 526 491 higher BMI. This surgery can result in two-thirds of excess weight monocentric randomized trial has compared it to the RYGBP, which 527 492 loss within 2 years, albeit, with specific nutritional deficiencies re- remains the gold standard [62]. 528 493 quiring replacement [8–10,53]. The complication rates are about 10% 494 in expert centres [10]. The main technical problem after gastric 529 495 bypass is anastomotic leakage, which in large series may reach 5% 6.3. Biliopancreatic diversion 530 496 [5]. It is a feared early complication appearing most commonly at 531 497 the gastrojejunostomy in RYGB with the incidence associated mor- Bilio-pancreatic diversion (BPD) is a combination of being ini- 532 498 tality of 0.1% [53,58,59]. Higher BMI, male gender, re-operation, older tially restrictive but ultimately malabsorptive. Technically, BPD involves 533 499 age and surgeon’s experience are associated with higher anasto- a distal gastrectomy leaving a proximal stomach volume of 150– 534 500 motic leakage rates [60,61]. 400 ml. Depending on the BMI the ileum is divided 260–360 cm 535 501 proximal to the ileocecal valve, and the alimentary limb is con- 536 502 6.2. Omega loop mini gastric bypass (MGBP) nected to the gastric pouch to create a Roux-en-Y gastroenterostomy. 537 503 An anastomosis is performed between the excluded biliopancreatic 538 504 MGBP is being promoted as a quick and effective alternative to limb and the alimentary limb 60 cm proximal to the terminal ileum 539 505 the standard Roux-en-Y gastric bypass procedure. It works both by (Fig. 4). There is 1.1% 30 day mortality and a predicted 70–80% weight 540 506 restricting food intake at any one time, and by altering gut hor- loss at 2 years [11,63]. 541 507 mones involved in appetite control. It seems more efficient on weight Bilio-pancreatic diversion with (BPD-DS) is mildly 542 508 loss (70–80% at 2 years) and co-morbidities than the RYGBP, with restrictive and mainly malabsorptive. It is technically a modifica- 543 509 the advantage of being less technically difficult and less morbid, es- tion of the BDS incorporating a sleeve gastrectomy and a longer 544 510 pecially for multi-complicated obese and/or the super obese. There common limb. In BPD-DS, a vertical sleeve gastrectomy (SG) is con- 545 511 is immediate improvement of diabetes, with some patients coming structed and the duodenum is divided 4 cm distal to the pylorus. 546 512 off insulin within a few days post-surgery [62]. It consists of a unique The small bowel is divided at mid-point and the distal small bowel 547 513 gastro-jejunal anastomosis between a long gastric pouch (restric- (alimentary limb) is anastomosed to the duodenum. The ilio- 548 514 tive part) and a jejunal omega loop of 150–200 cm (malabsorptive pancreatic limb (proximal small bowel) is anastomosed to the ileum 549 515 part) (Fig. 3). In effect, therefore, about 2 m of small bowel has been 100 cm proximal to the terminal ileum (Fig. 5) [64]. There is a pre- 550 516 bypassed before absorption of food (and calories) can take place. dicted 75–80% excess weight loss at 2 years especially as the excision 551 517 Fewer calories absorbed means weight loss. It is clear that in the of the fundus in the sleeve gastrectomy would decrease circulat- 552 518 case of the MGBP there is only one anastomosis, whereas in the ing Ghrelin and reduce appetite [63]. However, the outcome of sleeve 553 519 RYGBP there are two – an upper and a lower. Because of this the gastrectomy when used primarily is the same as gastric bypass 554 520 MGBP can be done in less time than the RYGBP and – at least the- [61,63]. In BPD-DS, leakage from the staple line is more common 555 521 oretically – with fewer early complications. However, this procedure than anastomotic leakage and the total enteric leakage rate is 5% 556 522 could be at risk of biliary reflux and anastomotic ulcers with dys- [65]. Dumping syndrome and anastomotic ulcers are less likely as 557

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558 Fig. 4. Diagram of biliopancreatic diversion.

559

Fig. 6. (a, b) Single anastomosis duodeno-ileal anastomosis (SADI) procedure. 582

583

excess weight loss 5 years after SADI procedure remains compa- 584 rable to the DS at 90% (compared with 50–70% for the sleeve or 585 bypass) [67]. 586 560 Fig. 5. Diagram of biliopancreatic diversion with duodenal switch. 587 561 7. Complications 588 589 562 compared to a BPD procedure because of the preservation of the Patient education, thorough pre-operative work-up and regular 590 563 pylorus in BPD-DS [65]. follow-up avoid most complications of bariatric surgery. The surgery- 591 564 related complications are the usual complications of gastrointestinal 592 565 6.4. Single anastomosis duodeno- (SADI) surgical procedures and are managed similarly. These include 593 566 haemorrhage, anastomotic leak, and anastomotic strictures [68–70]. 594 567 10–20% of patients have a sub-optimal result following bypass The complications general to any abdominal operation include pneu- 595 568 or sleeve surgery. BPD-DS is quite a significant malabsorptive pro- monia, deep vein thrombosis, urinary retention and ileus. Small 596 569 cedure as there is usually only 1 m of ‘common’ limb of small bowel. bowel motility returns within a few hours and gastric and colonic 597 570 The extra weight loss in BPD-DS is offset by a significant risk of motility after a few days, depending on the degree of surgical trauma 598 571 protein or vitamin deficiency unless they are assiduous with their [7–9]. 599 572 diet, and a poorer quality of life from diarrhoea (6–8 times per day). 600 573 Single-anastomosis duodeno-ileal bypass with sleeve gastrec- 7.1. Management of side-effects of bariatric surgery 601 574 tomy is a simplification of the duodenal switch that may behave 602 575 as a standard biliopancreatic diversion but easier and quicker to The early unfavourable side effects of the bariatric gastric bypass 603 576 perform. Given its effectiveness as a primary surgery it is hypoth- surgery are dehydration and constipation, and the dumping syn- 604 577 esized that it would be successful as a second-step operation. The drome. Dehydration and constipation is a common problem and 605 578 anastomosis between the duodenum and the small bowel is central patients must get used to drinking on a regular basis aiming for 1.5– 606 579 to the procedure, and with a ‘common limb’ of small bowel mea- 2 l/day. Re-education and occasional laxatives are advised. Almost 607 580 suring 3 m long the increased bowel frequency is much less 85 percent of patients who have gastric bypass (bariatric) surgery 608 581 compared to BPD-DS (Fig. 6a,b) [66]. Initial reports suggest that the will experience the ‘dumping syndrome’ but surgical revision is a 609

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610 last resort [7–9]. Dumping syndrome requires re-education of patient operative period [76,77]. Although the laparoscopic approach may 679 611 with avoidance of precipitating food stuffs. Highly restrictive gastric result in higher rates, closure of potential defects at time of primary 680 612 pouch patients are advised to eat low volume meals frequently up surgery is not, however, universal. Standardization of the proce- 681 613 to 6 times a day and avoid a carbohydrate load which can lead to dures and new surgical techniques where the mesentery windows 682 614 dumping [71]. Although the mass is small, stoma ul- are surgically closed may reduce the rate to as low as 1% [77]. 683 615 ceration remains a problem. Anastomotic ulcers are usually late Incisional hernias can occur but are less common with the in- 684 616 complications of bariatric surgery and occur in 2% of patients within creased use of laparoscopic techniques [58,59]. The risk of additional 685 617 the first post-operative year, and then in 0.5% for up to five years surgery for symptomatic gallstones from the inadvertent va- 686 618 [72]. They are common in smokers and patients who are H. pylori gotomy is prevented by a prophylactic during the 687 619 positive. Such ulceration may respond to proton pump inhibition bariatric gastric bypass procedures [7–11]. Hypersideroblastosis is 688 620 but revisional surgery may be required if the ulcer is resistant. Serum an uncommon problem due to hyperplasia of the B cells of the pan- 689 621 gastrin levels may become excessive and the excluded stomach may creas as a result of excessive weight loss giving rise to chronic 690 622 require resection [60,61]. A fistula between the pouch and the re- hypoglycaemia. Pancreatic resection may be required [71]. 691 623 Q4 maining stomach must be excluded [71]. 692 624 8. Revision gastric bypass (bariatric) surgery 693 625 7.2. Nutritional and vitamin deficiencies 694 626 As the number of primary bariatric procedures increases so does 695 627 Nutritional and vitamin deficiencies are late complications and the rate of re-operations as a consequence of either a failed primary 696 628 patient compliance is the major cause of such problems. BPD and procedure or complication. It is important to evaluate whether the 697 629 BPD-DS would initially require a post-operative diet high in protein cause is a technical failure or due to poor patient compliance. Dis- 698 630 (60–80 mg) [42,73]. Vitamin supplementation on a daily basis is es- cussion at the bariatric MDT is important in managing such patients 699 631 sential and a B12 injection at maintenance dose usually suffices [73]. with re-referral to both dietetics and psychology. Redo bariatric 700 632 Internal hernias may easily develop after laparoscopic gastric bypass surgery is associated with a higher mortality (2%) and morbidity 701 633 in which small mesenteric defects (transverse mesocolon, entero- (13% leak rate) compared with the primary operation [71]. Ana- 702 634 enterostomy or behind the Roux limb) can be created and there are tomical assessment includes plain radiography, contrast swallows, 703 635 fewer adhesions to tether small bowel loops and prevent them from and contrast follow-through studies for a ‘road map’ of the surgi- 704 636 herniating [74]. In addition patients who have greater degree of cally altered anatomy of the upper GI tract. is a useful 705 637 weight loss after laparoscopic Roux-en-Y gastric bypass may be more adjunct in looking at anastomotic strictures, ulcers and assessing 706 638 prone to internal hernia because of loss of the protective space- pouch sizes. Blood tests are needed for a full haematological and 707 639 occupying effect of mesenteric fat [75]. The reported frequency ranges biochemical profile including trace elements and vitamin D. The 708 640 from 0.4% to 5.5% in RYGB [76]. Long-term data over seven years revisional surgical approaches may include reversal of the obso- 709 641 record a hernia rate of 38% in BPD/BPD-DS [77]. High index of sus- lete jejunal–ileal bypass (high incidence of malabsorption), reversal/ 710 642 picion is required in all patients with abdominal pain with or without revision of Roux-en-Y gastric bypass and BPD/switch for 711 643 small bowel obstruction. Delayed diagnosis may lead to life- malabsorption, removal of eroded pre-anastomotic rings in Roux- 712 644 threatening complications of strangulation in the early or late post- en-Y bypass pouches (e.g. Fobi ring) and revision of gastric pouches, 713

645

646 Table 1 647 Q11 Summary of gastric bypass procedures. 648 Procedure Principle of action Malabsorptive/bypassed limb Mean excess 30-day Side effects 649 weight loss mortality (%) 650 Billroth II gastrectomy Non- primary bariatric 50–70% at 2 yrs 0.5 Bile reflux gastritis, stomal 651 (restrictive) ulcers, dumping syndrome 652 Diarrhoea 653 Mild B12 deficiency 654 Iron deficiency anaemia 655 Roux-en-Y gastroduodenal Primary bariatric (restrictive Gastric pouch (15–30 ml) 60–80% at 2 yrs 0.1 Dehydration and constipation, 656 bypass and malabsorptive) 100 cm jejunum (BMI <48 kg/ dumping syndrome, 657 m2) anastomotic ulcers, nutrition 658 150 cm jejunum (BMI >48 kg/ and vitamin (B12,D) 659 m2) deficiencies, internal hernias 660 Omega loop mini gastric Primary bariatric (restrictive Long gastric pouch (restrictive 70–80% at 2 yrs 0.1 Biliary reflux, anastomotic 661 bypass (MGBP) and malabsorptive) part), jejunal omega loop of ulcer, dysplasia 662 150–200 cm (malabsorptive 663 part) 664 Bilio-pancreatic diversion Primary bariatric (restrictive Gastric pouch (150–400 ml) 70–80% at 2 yrs 1.1 Dumping syndrome, 665 (BPD) and malabsorptive) Absorptive ‘common’ limb anastomotic ulcers, vitamin 666 (60 cm proximal to terminal deficiency, bone 667 ileum) demineralization, protein 668 deficiency, diarrhoea, foul 669 smelling stool, anaemia, 670 internal hernias more frequent 671 Bilio-pancreatic diversion Primary bariatric (mildly Sleeve gastrectomy 75–80% at 2 yrs 1.1 Similar to BPD but less 672 with duodenal switch restrictive and mainly Absorptive ‘common’ limb dumping syndrome and 673 (BPD-DS) malabsorptive) (100 cm proximal to terminal anastomotic ulcers, severe 674 ileum) protein deficiency 675 Diarrhoea (8×/day) 676 Single anastomosis Primary bariatric (restrictive Duodeno-ileal bypass 75–80% at 2 yrs, 90% at 5 yrs Less diarrhoea than BPD-DS, 677 duodeno-ileostomy and significantly ‘common’ limb 3 m protein deficiency 678 (SADI) malabsorptive)

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Please cite this article in press as: Elroy Patrick Weledji, Overview of gastric bypass surgery, International Journal of Surgery Open (2016), doi: 10.1016/j.ijso.2016.09.004