Roux-en-Y gastric bypass is a type of bariatric surgery used to treat severe obesity. It is also the most common bariatric procedure performed in United States, and is considered by some surgeons to be the gold standard of weight-loss surgeries.
How is Roux-en-Y surgery performed?
There are several variations of gastric bypass procedures, which can be divided into three categories:
- Restrictive: Limits food intake by reducing stomach size.
- Malabsorptive: Limits food absorption by bypassing portions of the small intestine.
- Combination: Both restrictive and malabsorptive measures are used.
Although all gastric bypass procedures are restrictive, not all are malabsorptive. Roux-en-Y is a combination procedure, both restricting food intake and limiting food absorption.
In general, the procedure is performed laparoscopically, using instruments inserted through small incisions in the abdomen. If laparoscopy is not possible, a laparotomy is performed, and one large incision is made in the middle of the stomach.
Roux-en-Y gastric bypass involves two stages:
- Forming a small pouch in the stomach
The surgeon divides the stomach into a large section and a smaller section. The smaller section of the stomach is sewn or stapled to create a pouch, which can only hold a cup of food.
This new, smaller stomach restricts food intake significantly, meaning the patient feels full more quickly and, therefore, eats less.
- Bypassing part of the small intestine
The new, smaller stomach is disconnected from the majority of the stomach and the upper part of the small intestine and is then connected to part of the small intestine farther down, known as the “Roux limb”. This creates a “Y” shape. The technique is referred to as a “Roux-en-Y”.
When this part of the procedure is completed, food passes directly from the stomach to the lower part of the small intestine, limiting the absorption of calories and fat. However, it also limits the amount of nutrients the patient can absorb from food.
Roux-en-Y gastric bypass surgery is a technically complex procedure and requires advanced laparoscopic surgical skills.
How does Roux-en-Y compare with other procedures?
The four most commonly performed bariatric procedures are adjustable lap band—or laparoscopic adjustable gastric band—surgery, gastric bypass surgery, sleeve gastrectomy, and biliopancreatic diversion with duodenal switch.
Adjustable lap-band surgery does not alter the digestive tract. Instead, the amount of food the patient can consume is decreased because an inflatable gastric band is placed around the top of the stomach. The procedure requires long-term maintenance, and weight loss is slower than it is with the other procedures.
Gastric bypass surgery, of which Roux-en-Y is a variation, reroutes the digestive tract to reduce the quantity of food the patient can consume and the nutrients that can be absorbed. Complications such as malnourishment can arise because of reduced vitamin and mineral intake.
Sleeve gastrectomy reduces the size of the stomach rather than bypassing a portion of the stomach, as gastric bypass surgery does. Sleeve gastrectomies reduce hunger, but do not reduce the ability to absorb nutrients from food. People who undergo gastric bypass procedures tend to be more likely to keep weight off in the long term.
Nowadays, gastric bypasses and sleeve gastrectomies are the most popular options for bariatric surgery.
Biliopancreatic diversion with duodenal switch is a procedure generally reserved for severely obese patients, with a body mass index (BMI) of 50 kg/m2 or greater. It can help patients lose more weight than gastric bypass surgery or sleeve gastrectomy; however, it does carry an increased risk of nutritional deficiency, which can result in damage to the nervous system and conditions such as anemia.
Each of these procedures has advantages and disadvantages, and some procedures are better suited to certain candidates than others.
A fifth weight-loss option has recently arrived on the market. The Obalon Balloon System consists of three balloons that the patient swallows over a six-month treatment period. The balloon takes up space in the stomach, meaning that the patient eats less.
When accompanied by a healthy diet and exercise routine, this less invasive approach can facilitate weight loss by helping to change eating habits.
Who is a good candidate for a Roux-en-Y gastric bypass?
Roux-en-Y gastric bypass surgery is a major surgical procedure. The success of the operation depends in large part on the patient, who must make permanent changes to both diet and lifestyle and have realistic expectations about what surgery can achieve.
When considering whether this particular variation of gastric bypass is the best option for you, a surgeon will perform a thorough evaluation of your physical and mental health.
A Roux-en-Y gastric bypass might be suitable for you if:
- Your previous attempts to lose weight through diet and exercise have proven unsuccessful.
- You have a BMI of 40 or higher.
- You have a BMI of 35 or higher and suffer from weight-related health issues, such as type 2 diabetes, high blood pressure, heart disease, and sleep apnea.
- You are a teenager who has finished puberty and have a BMI of 35 or higher.
- You are committed to creating a healthier lifestyle in the time leading up to and following surgery to ensure the best possible results.
There are other medical requirements you must meet to be a candidate for a gastric bypass. After your first consultation, you will most likely be screened by a panel of health professionals that includes doctors, a dietician, a psychologist, and a surgeon to determine if Roux-en-Y surgery is the most suitable gastric bypass procedure for you or if another surgery or weight-loss method is more appropriate.
This screening also ensures that you are psychologically ready to undergo the rigors and demands of weight-loss surgery, which can exacerbate existing mental health conditions.
Some recent studies have noted an increased risk of suicide in people who have undergone weight-loss surgery; however, this risk is more pronounced among people who have tried to commit suicide in the past. Patients need to be evaluated on a case-by-case basis, and closely monitored and supported, if necessary.
During your evaluation for Roux-en-Y gastric bypass surgery, your team of health professionals will consider:
- Your nutrition and weight history, including attempts at dieting in the past, eating habits, exercise regime, and motivation.
- Your current state of physical health. Certain medical conditions can increase the risks associated with surgery or be exacerbated by surgery, such as liver disease, heart conditions, kidney stones, and nutritional deficiencies. The medical team will also consider any medications you take, your alcohol intake, and whether you smoke.
- Mental health conditions, such as binge-eating disorders, substance abuse, anxiety disorders, and depression.
- Your personal motivation, willingness and ability to carry out prescribed changes in diet and exercise.
The existence of mental or physical issues does not necessarily preclude you from undergoing gastric bypass surgery, but it could mean that your surgeon will postpone surgery until the issue is appropriately treated or managed.
Advantages and disadvantages of Roux-en-Y gastric bypass
All gastric surgery procedures can help an obese person lose approximately 100 pounds of excess weight. They can also reverse health conditions linked to obesity, such as heartburn, reflux, and type 2 diabetes.
Roux-en-Y has its own benefits and limitations as a gastric bypass technique.
- The procedure is particularly effective for patients with a higher BMI because weight-loss outcomes are more predictable.
- It has a positive effect on diabetes and causes an almost immediate reduction in the need for diabetes medication.
- The procedure also has positive effects on high blood pressure and high cholesterol.
- It does not require any ongoing adjustments, unlike other gastric procedures, such as the lap-band procedure.
- The mortality rate of Roux-en-Y gastric bypass is low, at less than 0.1%.
- A Roux-en-Y gastric bypass is complicated and requires an advanced understanding of laparoscopy.
- The procedure is difficult to reverse, so reversals are only undertaken in rare situations.
- Complications that do arise tend to be more serious than those of other weight-loss procedures because of the magnitude of the surgery.
- There is an increased risk of nutritional deficiency due to the malabsorption of vitamins and minerals. Regular dietary supplements are essential to prevent malnourishment after surgery.
- Long-term follow-ups with surgeons and dieticians are necessary to monitor progress and nutritional status.
Finding a gastric bypass surgeon
Roux-en-Y gastric bypass is a surgery that requires ongoing contact with a surgeon, during both the preoperative and postoperative periods. For a sustained period of time after surgery, you will need to check in regularly with your surgeon to ensure you are deriving the best possible results from the procedure.
For this reason, it is vital to find a board-certified bariatric surgeon with verified credentials. Surgeons with certification from the American Society for Metabolic and Bariatric Surgery (ASMBS) are specialized in performing bariatric procedures and must meet strict continuing education requirements to maintain their certification.
Surgeons who perform gastric bypasses in clinics designated as Bariatric Centers of Excellence (COE), which are awarded by the ASMBS, have the highest possible standards of patient care and safety. Clinics with this designation must perform a minimum of 125 procedures per year and meet specific resource and care standards.
Although there are excellent surgeons and clinics that might not have these certifications, meeting the standards of the ASMBS provides a guarantee that you will be in the best possible care. The Roux-en-Y procedure in particular is complex, requiring a level of laparoscopic knowledge that takes up to 100 surgeries for a surgeon to master.
Bariatric surgery performed in non-accredited facilities can mean a greater risk of complications or adverse effects.
When you begin your search for a surgeon, you should also take the following points into account.
Do you feel at ease around the surgeon, comfortable to ask questions and raise concerns? The relationship will extend beyond the completion of your surgery, so finding a surgeon you can relate to is vital.
The best surgeons will encourage you to begin changing your diet and lifestyle as soon as possible, in preparation for surgery, and encourage you to join support networks.
You may have friends or family who have successfully undergone a Roux-en-Y gastric bypass procedure who can recommend a surgeon. Recommendations can represent a good starting point when you make your short list of potential surgeons.
There will be many pre- and postoperative visits, so a surgeon who works relatively close to where you live is a good idea. Although this is not always possible if you live in a rural area, patients generally find it easier to keep appointments and follow guidelines when the surgeon is easily accessible.
Roux-en-Y gastric bypass is an expensive procedure. If you have coverage from your health insurance policy, you can check your insurer’s list of approved surgeons. If your surgeon of choice is not listed, there is a chance the insurance company will add that surgeon, if asked.
Also, bear in mind that many surgeons offer patients free advice or seminars about financing options and insurance for gastric bypass surgery. They might be able to help find out if you qualify for bariatric surgery and help you appeal denials from your insurance company.
Cost of Roux-en-Y gastric bypass surgery
The average cost of Roux-en-Y gastric bypass surgery is around $25,000. Many practices quote patients an all-inclusive, upfront cost. This includes hospital fees, lab tests, anesthesia, surgeon’s fees, and pre- and postoperative consultations, which can continue for a year or more after your surgery.
If you have health insurance that covers the cost of a Roux-en-Y gastric bypass, you can expect to pay about $3,500 in costs. Note that some practices only work with patients who have health insurance.
The cost of surgery can vary, however, and is dependent on several factors:
- The surgeon’s experience
Surgeons with excellent reputations who specialize in Roux-en-Y gastric bypass surgery can set higher prices.
- Location and accreditation
Bariatric surgery clinics that have achieved Center of Excellence status offer the highest possible standards in patient safety and care, and the hospital fees can reflect this. Insurance companies often require patients to undergo surgery in facilities with COE accreditation.
Geography also affects the cost of surgery; surgery performed in clinics located in higher-density metropolitan areas generally cost more than those located in rural areas.
- Your insurance plan
The out-of-pocket costs you ultimately pay will depend on the level of coverage you have. If you are considering undergoing gastric bypass, make sure you consult with your insurance provider and thoroughly understand what they will and will not cover.
» If you would like to undergo Roux-en-Y gastric bypass surgery but are not covered by insurance, there are other financing options available you can consider. Read our CareCredit financing guide.
The months before the procedure
Proper preparation for a gastric bypass procedure is essential and involves both short-term and long-term planning. Committing to serious lifestyle and diet changes in the six months leading up to surgery will help ensure that you get the best possible results.
Patients who lose weight during the lead-up to the procedure tend to lose more weight after surgery and are less likely to experience complications. A Stanford University School of Medicine study showed that average operating time was 36 minute shorter when patients lost in excess of 5 before surgery.
The same study showed that for every 1% of weight lost prior to the procedure, a patient can expect to have lose 1.8% more weight one year after the surgery.
Weight-loss surgery will not work over the long term if you do not change your habits. Replacing poor habits with new and healthy habits takes time, so the more time you give yourself to practice new and positive behaviors, the better.
Schedule any presurgery lab tests or physical exams that your surgeon requests. These help determine if you are a good candidate for surgery.
Organize your paperwork. Insurance companies require a range of documents, such as your medical records, psychological evaluation, and letters of medical necessity, to approve gastric bypass surgery.
Your pre-surgery diet
Many insurance companies require adherence to a physician-supervised diet before you undergo surgery, which will most likely include the following instructions.
- Remember to eat for health. Once you have completed surgery, your stomach will be significantly smaller and, therefore, have less room for food. It is vital that the foods you eat are as nutrient-dense as possible so you can maximize your vitamin and mineral intake. Filling up with junk food will lead to malnourishment, and unpleasant side effects, like dumping syndrome.
- Practice eating slowly, chewing each bite, and watching the portion sizes. It takes 20–30 minutes for your brain to realize your stomach is full. Slow, mindful eating helps you to avoid overeating.
- Get into the habit of taking a multivitamin every day. After surgery, it can be difficult to obtain all the vitamins and minerals you need from much smaller quantities of food, so supplements are normally necessary. Start incorporating supplements into your diet as soon as possible.
- Don’t drink with your meals. After surgery, you will need to wait an hour after meals before you drink. Liquids move food through your new stomach pouch faster, leading you to feel hungry sooner and causing to eat more.
- Avoid sugary beverages, such as soft drinks and juice, and reduce your coffee intake. Drink plenty of water instead — this will help you feel full and promote weight loss, keep you well-hydrated, and flush out your kidneys, reducing the chance of kidney stones, which can occur with rapid weight loss.
- Eliminate alcohol from your diet. Your digestive system will be different after surgery and you will be more susceptible to intoxication. Alcohol after surgery can cause your blood sugar to spike, placing you at risk of health problems.
Start to build up your fitness gradually by moving every day, for as little as 20 minutes. Choose exercise that you enjoy. Exercise reduces the risk of complication during surgery and helps with weight loss.
Quit smoking, as it increases the risk of blood clots after surgery. Research shows that smokers fail to complete preoperative weight loss programs at twice the rate as nonsmokers.
Attend support group meetings. Participating in support meetings allows you to gain insight into other patients’ experiences, and they offer an invaluable source of support.
The week before surgery
Plan your recovery period ahead of time by preparing a checklist that covers the following to-dos:
- Make sure you’ve scheduled enough time off work. The average recovery period from Roux-en-Y gastric bypass surgery is four to six weeks. You’ll need that time to get used to the changes that come with a smaller stomach, such as the foods and eating habits that your body can and cannot tolerate.
- Fill your postop prescriptions. This way you will not have to worry about getting pain relief or other medications while you are at home recovering.
- Organize support people. You will need help from friends and loved ones as you recover to assist with childcare and help you with everyday tasks at least during the first week of your recovery.
- Purchase food and vitamins. Your surgeon will provide you with instructions about your postoperative diet and identify what is appropriate to eat at each stage of your recovery.
The day of surgery
The night before surgery, you will be asked to not drink or eat anything. In the morning, take a shower and wash your hair; proper bathing will be difficult in the week after surgery. Remove any jewelry or piercings, and make sure your skin is clean. Do not apply any lotions, moisturizers, or makeup.
When you arrive at the hospital, a team of nurses will prepare you for surgery. They will check your vital signs and inform you about what to expect. A wait of up to two hours before surgery is normal. Try to take a short walk while you’re waiting.
Surgery usually takes three to four hours and includes the following steps:
- The patient is given anesthesia.
- For a laparoscopic Roux-en-Y gastric bypass, the surgeon makes small incisions in the stomach, through which surgical tools are inserted.
- The surgeon uses a laparoscopic stapler to make a small stomach pouch in the upper part of the stomach. This new pouch holds about an ounce of food and empties directly into the middle of the small intestine, bypassing most of the stomach.
- The surgeon then uses the stapler to divide the upper part of the small intestine into a tube with two ends.
- One end of the small intestine (the Roux limb) is brought up to the stomach pouch and the two are connected.
The other end of the small intestine is connected to another part of the small intestine, forming a new digestive tract.
- The surgeon tests for leaks using dye or an upper endoscopy.
- The patient is closely monitored for several hours after surgery to check for any complications.
Patients usually remain in the hospital for one to two days after Roux-en-Y gastric bypass.
During this time, your surgeon and the nurses taking care of you will teach you wound care, how to care for your dressings, pain medication, and when to start physical activity. You will be encouraged to engage in gentle movement, such as walking, to minimize the risk of blood clots.
When you return home, ensure that you have a family member or friend to take care of you for the first week. Everyday tasks will be challenging and you will most likely need some support and assistance. Your stomach may feel sore for several weeks after surgery, so use pain relief when necessary. If you have been prescribed antibiotics, take them as directed.
A range of emotional responses is common during recovery. There might be times you feel happy and excited as you start to lose weight. But you might also feel overwhelmed and frustrated with the dietary and lifestyle changes requires. Being part of a support group can help you to manage your emotions during this time.
- Eating and nutrition
You will be given a diet and nutrition plan that you must follow. Most patients adhere to a liquid diet for the first one or two weeks after surgery to help the newly formed stomach pouch heal.
Soft foods will slowly be introduced, and then one month after surgery, you can start eating regular food. Make sure you remain adequately hydrated during this transitional time to prevent dehydration.
Supplements will be an integral part of your new diet, and can include daily multivitamins, calcium supplements, vitamin B12 supplements, vitamin D, and iron tablets.
Nutritional deficiency can happen quickly after surgery, so be sure you take any prescribed supplements regularly. You will require twice-yearly blood tests to check that you are receiving adequate quantities of vitamins and minerals.
- Wound care
If you have any strips of tape on your incisions, leave them on for a week, or until they fall off. If you have bandages, wash the area beneath the bandage daily with antibacterial soap and pat it dry. Keep your incision sites and surrounding areas clean and dry.
Your surgeon will give you specific directions about the exercises you should engage in during the various stages of your recovery. In general, patients are encouraged to start moving as soon as possible
Gentle walking is ideal and is an activity you can increase slightly every day. Avoid heavy lifting or strenuous activity, such as weight lifting, until your surgeon gives you the all-clear. More intense physical exercise can usually be resumed after three to four weeks.
- Follow-up visits
Maintain any follow-up visits that have been scheduled with your surgeon or dietician. These are critical to the success of your gastric bypass because they allow the specialists to check on your progress and recovery and implement long-term dietary plans.
- Emotional and physical changes
Most weight loss occurs in the immediate postoperative period and continues for about 12 months before your weight begins to stabilize.
During this time, you might notice a series of changes in your body, such as hair loss for three to six months after surgery, sagging skin, dental problems, gallstones, and kidney stones. Many of these side effects will subside over time.
You might also notice changes in your relationships with others, which can be both positive and negative. Positive changes can include increased romantic interest and greater respect from others, and negative changes can include jealousy and lack of support from overweight family members or friends.
Involvement in support groups can help you navigate these changes and your own emotional responses.
On average, patients require two to four weeks before they feel well enough to return to work. It is essential to give your body the time it needs to recover and become used to its new stomach pouch and digestive tract.
Results and satisfaction rates
Roux-en-Y gastric bypass surgery has been shown to produce significant weight loss in severely obese patients, helping them reclaim their lives. In one clinical study, 95% of patients reported a significant improvement in their quality of life after undergoing gastric bypass surgery.
In many studies, patients have reported a loss of 60% to 70% of excess body weight. Long-term weight loss has been shown out to ten years, or even longer. However, weight reduction depends on your behavior and the adoption of new and healthy eating and exercise habits. Overeating can stretch your new stomach pouch, compromising your ability to lose weight.
Roux-en-Y gastric bypass surgery not only results in significant weight loss, is also linked to improved health. Many patients note an improvement in obesity-related health issues, such as high cholesterol, hypertension, joint or bone disease, heart disease, and type 2 diabetes. For some patients, the condition can go into remission.
Patients who maintain follow-up appointments with their surgeons in the year after the procedure are more likely to see greater improvements.
» If you have lost a significant amount of weight as a result of a gastric bypass and are contemplating plastic surgery to excise or lift sagging skin, you can contact a board-certified plastic surgeon near you.
Potential risks and complications
All surgical procedures carry a certain level of risk. Before you commit to Roux-en-Y gastric bypass, it is important that you understand the risks and possible complications that can arise.
The following list includes information about the range of complications and side effects that can occur after the procedure, although many of the issues listed are rare and very unlikely to occur.
Acute complications that can occur soon after surgery:
- Gastrointestinal bleeding: This occurs in fewer than one in 100 patients after surgery, but can require a blood transfusion or, more rarely, reoperation.
- Infection: Generally, infections can be treated effectively with antibiotics.
- Leak: Fluid can leak through the new connection between the stomach and small intestine. This usually happens in the first few days after surgery and requires reoperation. Persistent leaks can result in infection or abscesses. If this happens, hospitalization might be required for an extended period of time.
- Ulcers: Ulcers can form in the new stomach pouch, and can be treated with anti-ulcer medication and careful adjustments to diet.
- Blood clots: Deep vein thrombosis or pulmonary embolism can occur after surgery. Gentle movement after the procedure can help reduce the risk of clots.
Longer-term complications include:
- Wound hernia: The incisions made in the abdominal wall can sometimes develop a hernia, which require urgent assessment if it is inflamed and painful.
- Anastomotic stricture: The new connection between the stomach and intestine must be kept small so that weight loss can occur easily. In some cases, the connection is too tight and requires stretching with endoscopy.
- Internal hernia: In rare cases, the loops of the bowel can become entangled. This requires reoperation to treat the problem.
- Adhesions: Adhesions, also known as scar tissue, can occur after surgery and cause the bowel to become stuck or twisted. These require hospitalization and, in some cases, reoperation.
- Weight regain: This occurs when dietary advice is not followed. Eating too much food at once can cause the small stomach pouch to stretch over time, making it easier to consume larger volumes of food in the future.
- Dumping syndrome: This occurs in up to 70% of gastric bypass patients. It is usually linked to poor food choices, such as foods high in sugar or fat that pass too quickly into the small intestine. Symptoms include cramping, nausea, dizziness, weakness, and fatigue. However, some patients report that it can be a positive side effect because it makes rejecting unhealthy foods easier.
Latest advances in Roux-en-Y gastric bypass surgery
Roux-en-Y gastric bypass surgery is subject to ongoing innovation and research. At present, significant research is being conducted to determine how to improve patient safety and lower the risk of complications.
One recent advance is the use of robotics in Roux-en-Y gastric bypass surgery, using the Da Vinci Surgical System. Initial studies have shown the potential to reduce complication rates, shorten hospital stays, and shorten the length of surgery; however, the use of robotics during the procedure is still limited.