Roux-en-y procedure

1. Roux-en-y procedure Ri ??? 2007/9/24

4. Characteristics intrinsic aboral peristaltic propulsive action ? conductive, not a capacitance, tube unidirectional aboral peristaltic action offers the property of a one-way valve ? reflux is prevented. ?exploited to allow esophagojejunal anastomosis and drainage of the biliary and pancreatie ducts. ?valuable means of draining cysts and fistulas.

5. jejunum transected and straightened, it can be extended to a greater distance from its vascular anchorage the rapid clearance of the jejunal segment ensures that there is little absorption within it

6. Complications Wound infection Intra-abdominal abscess Leak/ Bleeding/ Stenosis Internal hernia Pulmonary embolism

9. Anemia, metabolic bone disease, nutritional deficiencies (iron, calcium, vitamin B12 and folate), Gastric ulcer can occur in 3% of the cases, but can be cured most often by drugs. Stenosis of the anastomosis occurs in 5 to 7% of the cases, with vomiting, and can be cured by endoscopic dilatation. Biliary tract stone Late small bowel obstruction due to adhesions or an internal hernia

10. Postgastrectomy Syndrome Afferent and efferent loop syndrome Dumping syndrome Alkaline reflux gastritis Nutritional disturbance Retained antrum syndrome Marginal ulcer Postvagotomy diarrhea Postvagotomy atony Incomplete vagal transection

11. Early dumping syndrome intake of highly concentrated substances too quickly before they are digested ?concentrated highly osmolar substances travel the shortened distance to the lower intestine quickly ?fluid shift into the small intestine ?release of serotonin, bradykinin-like substances, neurotensin, and enteroglucagon ?cramping, tachycardia, diaphoresis, vomiting, or diarrhea in the early dumping phase (20~30mins)

12. long-acting octreotide for prevention of sym., vasomotor and gastrointestinal ??gastric emptying / ?fasting or interdigestive small bowel motility pattern ?prolongation of intestinal transit of the ingested meal

13. Late dumping syndrome ?absorbing simple sugars in small bowel ?a rapid glucose spike in the blood ?triggering insulin overshooting ?hypoglycemia ?catecholamines release resulting in diaphoresis, tremulousness, lightheadedness, tachycardia, and confusion in late dumping phase (2~3hrs)

14. Ingest frequent small meals and reduce their carbohydrate intake Use of an antiperistaltic loop of jejunum between the residual gastric pouch and intestine

15. Alkaline reflux gastritis severe epigastric abdominal pain accompanied by bilious vomiting and weight loss not relieved by food or antacids vomiting may occur anytime during the day or night no clear correlation between the volume of bile or its composition and the subsequent development of alkaline reflux gastritis. No effective medical treatment

16. Nutritional disturbance J CLin Endocrinol Metab 91: 4223-4231,2006

18. Calcium/vit.D deficiency 10%/51% Defective absorption of fat-solubale vit. because of fat malabsorption? steatorrhea Fat malabsorption is due to the short common channel and delayed mixing of fat with pancreatic enzymes and bile salts as a result of bypassing the duodenum. bypassing the duodenum and proximal jejunum further aggravated as fatty acids bind calcium ?markers of bone turnover and/or?bone mass Metabolic bone disease (osteoporosis/osteomalacia) calcium carbonate(gastric acid) v.s. calcium citrate

19. Iron-deficiency anemia 52% malabsorption due to bypassing of the duodenum and proximal jejunum, the main sites for iron absorption intolerance to iron-rich foods, especially red meat reduced stomach production of hydrochloric acid required to reduce ferric iron to the ferrous state before it can be absorbed.

21. B12 deficiency 64% lower portion of the stomach is removed or partitioned off, chief and parietal cells are lost that secrete hydrochloric acid and intrinsic factor. pancreatic enzymes as B12 binder proteins are lost as the upper portion of the small intestine B12 absorption in the distal ileum is calcium-dependent ?B12 prophylactic supplementation with parenteral ,sublingual or intranasal preparations

23. Folate deficiency 38% Primary reason for folate deficiency is decreased folate intake. Malabsorption may not play a big role, ? because absorption can occur along the entire part of the small intestine with adaptation after surgery ?prevent megaloblastic anemia

24. Protein malnourishment small pouch size ?extremely diminished amount of calorie intake bulk of digestion occurs in the small intestine/ loss of gastric/pancreatic enzymes? animal proteins more difficult for bypass patients to digest and absorb. ? Muscle catabolism and wasting

25. Gallbladder stone weight reduction with low-calorie diet, incidence of gallstones increases mechanism not completely understood, ?increased saturation of bile and stasis ?increased gall-bladder secretion of mucin and calcium ?increased presence of prostaglandins and arachidonic acid Ursodeoxycholic acid administered effective in preventing gallstone formation

26. Thanks !