Normal Anatomy and Complications of Bariatric Surgery:
An Interactive Teaching File with CT-Fluoroscopic Correlation

What is Roux-en-Y Gastric Bypass?

• Most common bariatric surgery, most often performed laparoscopically.
• Division of the stomach by stapling into a small pouch and attaching this pouch directly to the jejunum, Roux limb.
• Weight loss is due to restriction and malabsorption.

Indications

• Morbid obesity with BMI >40 kg/m²
• Morbid obesity with BMI 35-39.9 kg/m² with at least one serious comorbidity such as : Type 2 Diabetes, Hypertension, Hyperlipidemia, NASH, NAFLD, OSA, ....
• Morbid obesity with BMI 30-34.9 kg/m² AND Uncontrolled type 2 or Metabolic Syndrome

Contraindications

• Crohn's disease
• Chronic glucocorticoid or nonsteroidal anti-inflammatory use
• Uncontrolled psychiatric illness
• Coagulopathy

Laparoscopic

• Division of the falciform ligament
• Creation of retrocolic or antecolic passageway of the Roux limb
• Jejunojejunal (JJ) anastomosis
• Creation of gastric pouch
• Gastrojejunal (GJ) anastomosis
• Intraoperative leak test
• Closure of the potential hernia sites
• Drain placement

Considerations

• Bypass length
• Antecolic vs retrocolic passage of the Roux limb

Advantages

• Similar to sleeve gastrectomy in terms of weight loss.
• Better suited for patients with GERD or Barret's esophagus

What is Roux-en-Y Gastric Bypass? CT Case Study 1 CT Case Study 2 Medical Illustration

• Most common bariatric surgery, most often performed laparoscopically.
• Division of the stomach by stapling into a small pouch and attaching this pouch directly to the jejunum, Roux limb.
• Weight loss is due to restriction and malabsorption.

Dumping Syndrome

• Most common complication up to 50%
• Post prandial flushing, diaphoresis, palpitations, and diarrhea.

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Anastomotic Stenosis

• 6-20 % develop stromal stenosis(less than 10 mm in diameter) at the anastomosis site several weeks post-op.

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Marginal Ulcers CT Case Study 1 CT Case Study 2 Medical Illustration

• 1-16 % develop marginal ulcers near the gastrojejunostomy due to gastric acid injuring the jejunal mucosa.
• Other causes include gastrogastric fistula, ischemia at anastomosis, foreign material such as staples, NSAIDs use, or H-Pylori.

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Internal Hernia Medical Illustration

• Less than 5%

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Cecal Volvulus CT Case Study

• Cecal volvulus is an uncommon complication, with a few cases reported in the liturature.

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Small Bowel Obstruction CT Case Study 1 CT Case Study 2 Medical Illustration

• Less than 5%

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Leak

• Less risk than gastric sleeve (2.4 versus 0.7%)

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Gastrogastric fistula CT Case Study 1 CT Case Study 2 Medical Illustration

• 1-2 %
• Associated with marginal ulcer and weight regain.

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Gastric remnant distention

• Rare but potentially lethal due to rupture.

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Candy cane Roux syndrome

• Patients present with postprandial pain relieved by vomiting
• The afferent loop is distended with food, relieved when it empties into the Roux limb or vomited out

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Other: short bowel syndrome, cholelithiasis, nephrolithiasis, incisional hernias