Op. Dr. Cemal Kara

GASTRIC BYPASS

Detail information about Gastric Bypass.




  1. What is Gastric Bypass surgery?

By pass means to use shortcut. Gastric Bypass refers to the creation of a pathway from the stomach to the intestines in general surgery. It is a method applied in various diseases that obstruct the stomach exit. The term “Gastric bypass” used in bariatric surgery is a surgical procedure in which the majority of the stomach is disabled and the received food is digested using almost half of the intestines.

  1. Which Patients are treated with Gastric Bypass surgery?

It can be applied to patients with obesity who are unable to lose weight or who have weight-related insulin resistance, joint problems, etc.  It was the most common surgical method until five years ago. However, the frequency of its implementation decreased as the sleeve gastrectomy became more popular. It is now applied as a second operation (revision surgery) in patients who gain weight after sleeve gastrectomy. As a revision surgery, it can also be applied to patients who have previously undergone sleeve gastrectomy, gastric band, gastric plication or vertical gastroplasty. Again all of these procedures can be performed laparoscopically (closed).

  1. Do diseases such as diabetes, asthma, blood pressure prevent Gastric Bypass surgery?

On the contrary, these are diseases caused and exacerbated by obesity. These diseases are not an obstacle for the surgery but they are the reason.

  1. How to prepare before Gastric Bypass surgery, which examinations are done?

First, the following tests and examinations are applied to each patient before surgery

  1. Blood biochemistry tests
  2. Hemogram
  3. Hormone tests
  4. Hepatitis tests
  5. Whole abdominal ultrasound
  6. Gastrointestinal Endoscopy (with anesthesiologist)
  7. ECG (Electrocardiography)
  8. Chest radiography
  9. Pulmonary function test
  10. Effort test and ECO (Echocardiography) if required

After all these tests, necessary examinations are carried out by Anesthesia, Internal Medicine, Cardiology, Chest Diseases and Endocrine specialists. As a result of these examinations, firstly it is checked whether the patient has any other underlying disease that may cause weight gain. If there is no such disease, the patient will be examined for anesthesia like every patient who will be operated. Relevant specialists will make recommendations about pre-operative treatments if necessary. Thus, the problems that may arise during and after this significant surgery are reduced to the minimum.

  1. How is Gastric Bypass surgery performed?

All procedures are done by laparoscopic (closed) operation method. Laparoscopic surgery is performed with a large number of small incisions. The ports placed from these incisions are used to reach the abdomen by the hand tools. One of these is a surgical telescope connected to a video camera and others are for the insertion of specialized surgical instruments. The surgeon monitors the operation from a video monitor. With experience, an experienced laparoscopic surgeon can perform many procedures as laparoscopically as in open surgery.

Although the first gastric bypass was performed in 1967, the laparoscopic gastric bypass, Roux-en-Y, was first performed in 1993 and has been accepted as one of the most difficult operations to perform with limited access surgery. However, the use of this method has made this operation very popular due to the shortening of the hospitalization period, shortening of recovery period, fewer scars and reduced surgical site hernia. From the upper part of the stomach, which is joined with the esophagus, it is closed and cut off so that a small stomach part (5-10% of the whole stomach) is left on the side of the esophagus. Thus, a proximal gastric pouch smaller than 30 mL (at the entrance of the stomach) is formed.

This new stomach pouch has a smaller volume than about 1 tea glass. In this operation, unlike the “sleeve gastrectomy”, no part of the stomach is removed, but it is left in place. By creating a stomach pouch, the existing stomach is disabled and the food is directed here. It is taken from the part of the small intestine leading to the distal (large intestine), and approximately 50-75 cm is cut and connected to the new stomach pouch created. The remaining end of small intestine, from which the bile and pancreatic fluid come, is attached back to the intestine about 70-80 cm forward. All these cutting, separating, joining and ostomy operations are carried out with single-use special tools known as “stapler”.

  1. What are the different applications of Gastric Bypass?
  1. Gastric bypass, Roux-en-Y (proximal): This variant is the most commonly used gastric bypass technique and is the most applied bariatric procedure in the USA. This is the operation that leads to minimal nutritional problems. A proximal gastric pouch smaller than 30 mL (at the entrance of the stomach) is formed. This new stomach pouch has a smaller volume than about 1 tea glass. By creating a stomach pouch, the existing stomach is disabled and the food directed here. It is taken from the part of small intestine leading to the distal (large intestine), cut approximately 50-75 cm and is connected to the newly formed stomach pouch. The end of the small intestine that is left behind and through which the bile and pancreatic fluids come is re-associated to the intestine about 70-80 cm further.
  2. Gastric bypass, Roux-en-Y (distal)

The normal small intestine is between 600-1000 cm. At approximately 1 meter forward, one end of the intestine from which the bile comes is combined with the intestine from which the food comes. The association of bile with the food at the end of the small intestine is primarily responsible for malabsorption (reduced absorption) of fats and starches, but also of various mineral and fat soluble vitamin vitamins. Unabsorbed fats and starch pass to large intestine. This can lead to faster weight loss. However, more serious nutritional problems (e.g. severe vitamin deficiency) can be observed. Moreover, the bacterial activity therein may lead to the production of irritants and the formation of malodorous gas.

  1. Loop Gastric Bypass (Mini Gastric Bypass)

Here the intestine is directly connected to the stomach without being divided in half. Along with being simpler to form, this method leads to severe inflammation and ulceration in esophagus, as the bile and pancreatic enzymes leak from the small intestines to the stomach and then to the esophagus. Although its application is simpler, it is not a highly preferred method.

  1. Is the brand of materials used during Gastric Bypass surgery important?

There are many different products in the market. The materials of the two leading American companies are the best quality products currently on the market and used all over the world. However, their costs are much higher than Chinese products used for the same purpose. Safety, not cost, is of first importance in health. Each product used has its own barcode with serial number. The barcode of each used material is placed in the patient file. Absolutely ask for the material used.

  1. Is there a leak test on Gastric Bypass surgery?

Leak test is performed during the revision surgery and then on the 2nd day. The purpose of the leak test in the operation is to determine if there is a problem with the staples, whether there is leakage at the suture line. If there is leakage, additional suture is added to prevent leakage. It is also possible to take the necessary measures on time and to intervene by conducting a leak test before starting the liquid nutrients after the operation.

  1. Is there suture in Gastric Bypass surgery?

In bariatric surgery, additional suturing in addition to special materials called staples is controversial. Some surgeons think that suturing reduces the possibility of bleeding and leakage and that every patient should be sutured. Some surgeons say that suturing reduces the chance of bleeding to some extent but does not reduce the risk of leakage; in contrast, it may lead to more leaks and bleeding after vascular injury while suturing. We are among the two of them as a clinical approach. Although we do not use additional stitches to each patient, we will definitely add extra stitches if the stapler line is not safe enough for us. The fact that our results are much better than the average of the world suggests that our method is more successful. The most important point here is that the surgeon who performs the surgery must have the ability and experience to intervene and correct any problems.

  1. Why is blood thinner used in Gastric Bypass surgery?

During each surgery, there is a possibility of blocking blood vessels with          intravascular blood clots. This can lead to serious problems when it is a vessel that feeds vital organs such as the heart, lungs and brain. As the weight of the patients increases, the risk of embolism increases. For this purpose, blood thinners are given to these patients regardless of the surgery. Although the risk of bleeding is slightly increased, the benefit is much higher. The use of blood thinners begins before surgery and continues for two weeks. The duration of use may be even longer in high-risk patients, such as those with cardiovascular disease or previous embolisms.

  1. Will there be pain after Gastric Bypass surgery?

Since revision surgery is done laparoscopically (closed), by entering through millimetric holes, postoperative pain is much less than open surgery. Still, the phrase “she/he had a surgery, of course there will be pain” is extremely wrong. No patient should feel pain in the 21st century. Pain is completely avoided by administering post-operative analgesic to each patient. The important point here is this: Pain threshold of each person is different. Again, drug tolerance and bioavailability from the drug are different. Therefore, treatment cannot be standard. The pain relief treatment should be regulated separately depending on the needs of each patient.

  1. Will there be a scar after Gastric Bypass surgery?

Since the incisions are very small, the aesthetic results are also fairly good. After a few months, these lines will become almost invisible. After the wound heals, you will be recommended a cream for less scar appearance. You will get much better aesthetic results if you use it for three months.

  1. When nutrition will start after Gastric Bypass surgery?

On the 2nd day of the surgery, you will start taking liquid food after the leak test. You will have soft (puree style) food for two weeks following the first two weeks of fluid feeding. You will be in constant communication with our dieticians throughout this entire process.

  1. How will nutrition, vitamins and mineral supplements be provided after Gastric Bypass surgery?

During the first 15 days, protein supplements are provided for the patients. Especially in the first year of the disease various vitamin and mineral supplements are provided. Protein and vitamin usage times differ according to the type of surgery. These are not standard for every patient but are determined according to what the patient needs and how much they need after the examinations performed on the routine controls.

  1. Is it possible to get up and go back to work immediately after Gastric Bypass surgery?

Since surgery is done laparoscopically (closed), you can get up and walk after a couple of hours of surgery. Even during the period when you are in the hospital you will not be cared for, you will be able to do your own selfcare. Patients who work on desk and patients who do not require heavy effort can start back to work within a week. Patients who require heavy effort should stop working for at least one month. The resting report is given for as long as required to the patients after the surgery.

  1. When are the stitches removed after Gastric Bypass surgery?

It is not necessary to take the stitches as dissolvable stitches are frequently used. If a non-dissolvable stitch is used for a different reason, the stitch is checked and removed when you arrive for a follow-up on the tenth day.

  1. When can you have a shower after Gastric Bypass surgery?

You can take a shower when you’re out of the hospital. There is no problem with the sutures getting open and wet. After showering, dry with a clean towel, apply batticon on the sutures and wait for them to dry. Batticon does not cause permanent stain in your clothes. There is no need to use batticon after the tenth day.

  1. Can I use medication after Gastric Bypass surgery?

During the first month, do not use any medications except the ones we prescribe. If a medication is suggested by another physician, you should definitely consult us. You can use any medications after the first month. Nevertheless, try not to use too much painkiller and take plenty of fluid after taking the medication.

  1. How Gastric Bypass surgery works?

Gastric Bypass restricts both food intake and food absorption. Nearly 95% of the stomach and one meter of duodenum and small intestine is inactivated, meaning “by-passed” in the medical sense. Gastric bypass reduces stomach size by over 90%. Normal stomach can sometimes expand to 1000 ml. The gastric bypass pouch is 15-30 ml in size. Gastric bypass pouch is formed in the upper part of the stomach which is the least flexible part and there is no significant increase in the volume of the pouch in the long term. The first response when the patient takes a small amount of food is to strain the wall of stomach pouch and to warn the nerves that inform the brain about the fullness of the stomach. The patient feels a sense of satiety as if she/he ate a big meal, but it is actually a few spoonful meals. Many people do not eat when they feel satiated. However, patients quickly learn to eat their next bites very slowly and carefully to protect themselves from increased discomfort or vomiting. With this method, weight loss is more compared to restrictive methods. The person’s total energy intake is low and there is a high tendency to show intolerance to the food. In this regard, the patient can lose weight because he or she eats less and the food goes from the stomach directly into the end of intestine instead of the beginning of the intestine.

  1. Will there be weight gain after Gastric bypass surgery?

The risk of weight gain after a sleeve gastrectomy is very low. In order to maximize the benefits of this physiology, the patient only needs to eat at meals, take 2-3 meals a day, and avoid snacks between meals. This surgery requires changing the eating habits acquired over a long period of time. In almost all cases where weight gain was observed again in the late periods of surgery, there was no increase in the meal capacity. The reason why you gain weight again is especially high calorie snacks between meals. There is no known operation to overcome the side effects of this type of eating habit.

  1. What are the disadvantages of Gastric Bypass Surgery compared to Sleeve gastrectomy?
  1. It may cause more vitamin, mineral deficiencies (especially vitamin B12 deficiency, iron, calcium and folate deficiency).
  2. It requires diet suggestions, lifelong vitamin-mineral supplementation and follow-up.
  3. Intervention options that can be done again with weight gain are limited.
  4. When there is a problem, there is no chance to intervene in the bile ducts and the pancreatic duct with endoscopy. The procedures such as ERCP and biopsy cannot be performed.
  5. There is no chance of control of closed stomach tissue by endoscopy.
  6. The decrease in appetite is less compared to sleeve gastrectomy because the part of the fundus that secretes Ghrelin (appetite hormone) is not removed.
  1. What is the cost of Gastric Bypass Surgery? Is it an expensive surgery?

Our clinic has an agreement with social security institution (SSI) and serves as affordable as possible. You can get detailed information from our contact numbers.

The prices of bariatric surgery are slightly higher than other surgeries. However, a few titles are extremely important here.

  1. The materials used are an important cost item. There are many different products in the market. The materials of the two leading American companies are the best quality products currently on the market and used all over the world. However, their costs are much higher than Chinese products used for the same purpose. Safety, not cost, is of first importance in health.
  2. The operating room and the hospital where the surgery is performed must have certain equipments and standards. It is necessary to have sufficient number of intensive care beds and a full-time physician in all branches. All equipments from the operating table to the patient bed should be suitable for obese patients. Therefore, it is not appropriate to perform the procedure at every hospital.
  3. Bariatric surgery is not completed only with the surgery; there should be a support team with specialist dieticians whom you can reach for 7 days 24 hours.
  4. The cost of testing and preparation steps required for revision surgery is higher.

Meeting all these requirements increases the cost of surgery by a little more than other surgical procedures. Even if putting aside the quality of life, obesity is the actual cost considering in the long term.  The amount of money to be spent on the treatment of health problems caused by obesity such as joint erosions, diabetes, asthma, sleep apnea and blood pressure is several times higher.





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