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The gastric bypass surgery is an operative therapy option for weight loss. Normally, the predigested chyme enters the duodenum through the stomach. There it is used with the digestive juices from the pancreas and bile. By diverting the digestive juices, which are necessary for fat digestion, it comes to a significantly reduced fat intake.

In gastric bypass surgery, a large part of the stomach and a piece of the small intestine are removed. The remaining stomach and the remaining small intestine are connected again. Thus, the food passage is shortened and less food is digested.

The gastric bypass has the same position in the body after completing surgery as the previously complete stomach.

The small residual stomach is connected to the rest of the small intestine, so that the food passage is indeed shortened, but otherwise remains undisturbed (so-called alimentary leg). Finally, the digestive limb is sutured laterally about 100 cm behind the "new" gastric and small intestinal connection, so that the digestive juices flow later into the intestine. This reduces the fat digestion by about 40%.

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Gastric bypas is an interim goal in the obesity surgery and treatment. German experts for bariatric surgery will support you 2020-03-13 Gastric Bypass
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Gastric Bypass
Gastric bypass

The gastric bypass is a surgical procedure in obese patients that is used to bypass and thus exclude large parts of the stomach and the small intestine from the digestive process. With a small remaining stomach the patients feel satiety even after a very limited amount of food. The result is a fast and pronounced weight loss.

Gastric bypass (more precisely: Roux-en-Y gastric bypass) is a very common obesity surgery used to reduce weight. It is named after the Swiss surgeon César Roux, who developed the basic technique for the intervention. The "Y" represents the Y-shaped diagram of the way the intestinal sections are joined together.

Gastric bypass has been performed on 17,215 patients since 2005. There was a clear preference for laparoscopic access, over which 98.6% of the procedures were performed. Patients with RYGB (47.92 kg / m2) had a significantly lower BMI than patients with other procedures (50.27 kg / m2).

The success of a gastric bypass surgery is based on two principles:

  • The stomach reduction decreases the food intake (restriction)
  • Due to the elimination of the important upper part of the small intestine (duodenum), the digestive juices that break down food are mixed later with the food pulp (lower nutrient absorption = malabsorption)

The weight loss after a gastric bypass surgery is dramatic and reliable, but it is accompanied with some lifelong restrictions: Patients with a Reoux-en-Y-bypass may eat only very small portions, because after the operation the remaining stomach ("stomach pouch") has a very small volume. The poor nutrient utilization means that patients have to take life-long dietary supplements and vitamins (especially vitamin B12, trace elements and protein preparations) to avoid deficiency symptoms. Some of the nutrients remain undigested causing fermentation processes in the colon. However, the operation cannot be reversed after a successful weight reduction.

Gastric bypass is one of the most widely used and established methods of achieving significant weight reduction through surgery. Here, similar to the tubular stomach, the stomach is significantly reduced, so that much less food can be absorbed (restrictive component). Unlike the sleeve or stomach, however, the residual stomach is not completely removed, but remains in the body and produces digestive juices. In addition, the small intestine is redirected (bypass) so that food and digestive juices can mix later in the small intestine. Therefore, a part of the calories (fats and sugars) can not be digested, but leaves the body again with the stool. The reduced intake of calories, fats and nutrients is called malabsorption. Due to this mode of action, experts also refer to this procedure as a malabsorptive procedure or as a restrictive malabsorptive procedure.

The reduced absorption of the body for sugar, fats and other nutritional components promotes weight loss. At the same time, however, many nutrients, vitamins and trace elements can be ingested by the organism due to this surgical measure. This may require an additional intake of dietary supplements or mineral and vitamin supplements. For this purpose, every six months, check-ups should take place at the family doctor or in our center. The method known by many as 'gold standard' has been used by us since 2007. Again, similar to the other methods, a decision for or against this is very individual and can only take place in personal consultation.

There are also different methods of this procedure, which usually differ in the length of the different small intestine areas (loops). But also the size of the smaller stomach (pouches) can vary. In our center we inform you in great detail about the advantages and disadvantages of the different variants.

Omega loop bypass (also called "Mini" Bypass)

It is a variant of the gastric bypass and also a combined restrictive malabsorptive procedure.

The advantage of this method is a shorter operating time and risk reduction because of the saving of a suture connection in contrast to the Roux-Y-bypass and a possibly greater weight loss. Critics point out that there is an increased risk of ulcer formation and possibly also in the long-term course of carcinoma formation at the suture connection between stomach and small intestine, caused by the contact between bile juice and gastric mucosa. However, this presumption, based on decades of experience in gastric surgery, has not yet been proven in the medium-term follow-up periods.

The Omega Loop Bypass differs from the standard bypass in that it creates a slightly larger gastric pouch, which is then connected to the jejunum (ulcer) 200 to 250 cm after it starts. For this, the small intestine does not have to be severed. The dining passage thus bypasses parts of the stomach, the duodenum and the first 200-250 cm small intestine.

Because of the described problem we practice in our obesity center a modified method that prevents the contact between bile and gastric mucosa.

Preparation to gastric bypass surgery

Any pathological changes in the stomach need to be ruled out before the operation. This makes necessary a stomach examination for diseases such as gastric mucosal inflammation or gastric ulcers and for possible bacterial colonization with "Helicobacter pylori", which can cause gastric ulcers. In addition to a gastroscopy and the examination of the gastric juices, an ultrasound of the upper abdomen is also used to detect gallstones. These are removed in the course of gastric bypass surgery as they can lead to inflammation of the gallbladder and bile duct.

Gastric bypass surgery procedure

The gastric bypass surgery lasts about 90 to 150 minutes depending on the patient and is performed under general anesthesia. The surgery usually requires a hospital stay of about one day before the operation (surgical and anesthesia preparation) plus five to seven days after it. After the gastric bypass surgery, you will not be able to work for three weeks.

Gastric bypass is now performed almost exclusively using the so-called minimally invasive surgery. This technique, also known as the keyhole method, does not require a large abdominal incision. Instead, the instruments and a small camera are introduced into the abdominal cavity through several two centimeters long skin cuts. Minimally invasive operations generally have lower surgical risk compared to open operations and are therefore particularly suitable for obese patients who are already more vulnerable to complications during and after surgery.

Gastric bypass surgery consists of several stages:

  1. After the induction of general anesthesia, the surgeon makes several skin incisions to insert the instruments and the camera with a light source into the abdominal cavity. After that, gas (usually CO₂) is introduced into the abdominal cavity to lift the abdominal wall from the organs giving the surgeon more space in the abdomen and a better view of the organs.
  2. Then the stomach is cut off just below the esophagus using a special surgical stapler. The stapler cuts and clamps simultaneously so that the cut edges are closed immediately. Thus, only a small remaining stomach (the so-called gastric pouch or stomach pouch) is left at the end of the esophagus. It has a volume of less than 50 milliliters. The remaining stomach is left in the body but it is closed at the upper end and thus quasi "shut down".
  3. The next step is to cut the small intestine in the area of the so-called jejunum. The lower end of the cut is now pulled up and sewn to the stomach pouch. This connection is sometimes called gastrojejunal anastomosis.
  4. Then further below the remaining cut end of the jejunum is sewn with the third small intestine section ("ileum"), so that the Y-shape is formed (y-anastomosis). Only here the digestive juices from the duodenum (bile and pancreatic secretion) are mixed with the food pulp.

Who is gastric bypass suitable for?

The gastric bypass is suitable for people with a body mass index (BMI) of more than 40 kg/m² (Obesity Grade III or morbid obesity). In any case, the condition for a gastric bypass surgery is that all non-operative measures were not sufficiently successful even after six to twelve months. These measures include, for example, professional nutritional advice, exercises and behavioral therapy (multimodal concept for obesity, MMC).

To have a gastric bypass performed you should be at least 18 and not more than 65 years old. However the intervention is possible in younger or older people in individual cases. Gastric bypass surgery is particularly recommended for people whose excess weight is caused by consumption of rich in calories food (sweets, fats) and drinks. This type of food is broken down badly, and the body can utilize it only to a small extent storing it as body fat.

If metabolic diseases, such as diabetes mellitus, hypertension or a sleep apnea syndrome, are already caused by obesity, a gastric bypass surgery can already be performed in patients with a BMI of 35 kg/m².

Various physical and mental illnesses prohibit an obesity operation such as gastric bypass. A gastric bypass surgery cannot be performed after previous surgeries or in case of stomach malformations, gastric ulcers and addictions, as well as untreated eating disorders such as binge eating or bulimia. Pregnant women also have to forgo gastric bypass surgery.

Effectiveness of gastric bypass surgery

Gastric bypass is a very effective procedure, even though only few patients achieve normal weight (BMI ≤ 25 kg/m²). Studies have shown that in the long term a weight loss of about 60 to 70 percent of the excess weight is possible with a gastric bypass, i.e. the amount of weight that separates obese patients from the people with normal weight.

The weight loss after a gastric bypass operation has not only purely cosmetic effect, it also favorably impacts the metabolism. For example, in many cases, an existing diabetes mellitus is greatly improved and sometimes even cured. In many cases, blood glucose levels fall short after the operation, although the patient has not yet lost much weight. The reasons for this are yet unclear. It is suspected that various hormonal changes are set in motion by the operation (for example, such hormones as ghrelin, glucagon, GIP, etc.), which favorably affects the metabolism.

Advantages of gastric bypass surgery

Since the gastric bypass surgery combines two principles (restriction and malabsorption, see above), the procedure is extremely effective even if the patient's obesity is caused by excessive intake of liquid or soft high calorie food. For these so-called "sweet-eaters" the sole reduction of the stomach volume achieved through a gastric banding, gastric balloon or sleeve gastrectomy, would not be sufficient.

Side effects

Some side effects are associated with gastric bypass. Their strength differs in each individual case and therefore cannot be predicted. The most important side effects:

  • Digestive disorders caused by malabsorption: flatulence, abdominal pain, nausea, bloating
  • Iron deficiency and anemia: Most of the dietary iron is usually ingested in the duodenum. The gastric bypass diverts the food from the duodenum making the iron intake more difficult. The iron deficiency is prevented by additional iron intake.
  • Vitamin B12 deficiency (special form of anemia): Vitamin B12 is absorbed in the last section of the small intestine (terminal Ileum). However, this process requires an auxiliary, the so-called intrinsic factor, which is produced by the stomach. The gastric bypass, however, diverts the food from the stomach and thus less intrinsic factor is formed. Vitamin B12 must therefore be regularly injected intramuscularly or into the vein. Vitamin B-12 supplements are also available, which can be absorbed directly by the oral mucosa (sublingual application). However, their effectiveness is still discussed.
  • Vitamin D deficiency: why is gastric bypass causing a vitamin D deficiency is yet unclear. Vitamin D can be easily taken in with food (orally).
  • Dumping syndrome: A number of symptoms (dizziness, nausea, diaphoresis or palpitation), which are caused by an instantaneous (sudden) dumping of food from the esophagus directly into the small intestine, are referred to as dumping syndrome. It happens because the stomach pouch lacks the lower stomach sphincter (porter). In the small intestine, the osmotic forces make the food pulp absorb water from the surrounding tissues and blood vessels. This reduces the amount of fluid in the circulatory system, which can result in a blood pressure drop. A dumping syndrome occurs mainly after drinking very sugary beverages or eating fatty food.
  • Gastric ulcer in the stomach pouch: After gastric bypass surgery, the risk of a stomach pouch ulcer is increased. To cope with it the patient must take acid-reducing drugs, the so-called proton pump inhibitors (PPI), permanently, if a gastric ulcer occurred after a gastric bypass operation.
  • Loss of muscle mass: a fast weight loss is often associated with a loss of muscle mass because the organism tries to compensate for the relative deficiency of carbohydrates by degrading body proteins (mainly from less important muscle cells). Regular physical training can halt this side effect. Easy on the joints sports such as light weight training, cycling, swimming or aqua-jogging are especially advisable for obese people.

Gastric bypass: Risks and complications

Gastric bypass is a large abdominal surgery that greatly alters the normal anatomy of the gastrointestinal system. In principle, surgical risks are low, but complications cannot be ruled out as with any surgical procedure. Non-specific surgical risks include:

  • Anesthetic complications
  • Organ and vascular injuries with bleeding
  • Infections of internal and external wounds
  • Leaks of artificial organ connections (anastomoses) with risk of inflammation of the peritoneum (peritonitis)
  • Wound healing disorders
  • Disturbances of normal gastrointestinal movements (intestinal atonia)

Gastric bypass: Nutrition after surgery

Nutritional recommendations after gastric bypass surgery

Persons after gastric bypass surgery require regular follow - up care in the obesity surgery therapy experienced doctor and a nutritionist. In the first year after the operation four follow-up appointments should take place, then once a year. By checking the intake level and nutrient composition using nutritional protocols, nutrient deficiencies can be prevented by timely intervention. Laboratory controls with determination of the blood count and selected parameters of vitamins, minerals and

Trace elements are used to diagnose deficiency states. If the values ​​are below the norm, nutrient supplements must be prescribed (according to the European Recommended Daily Allowance, EU-RDA). A nutrient deficiency is more likely the more invasive a procedure is. Gastric banding or gastric tube scarcity often causes deficiencies in care, but gastric bypass and biliopancreatic diversion (BPD) are almost always absent. The supplements must then be taken a lifetime!

Gastric bypass: Costs

The cost of a gastric bypass differs considerably depending on the clinic. It ranges approximately between 6,500 and 15,000 euros.

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Gastric bypass: OP as the last chance, if all weight loss attempts fail


For some, the last resort is to get rid of morbid obesity: gastric bypass. But how does the surgery work and what are the risks?

Eating smaller amounts and at the same time being able to absorb fewer nutrients from the diet - this should enable gastric bypass surgery and thus help obese people to decrease. It is offered in the circle of Prof. Michael Korenkov, chief physician of general and visceral surgery at the Klinikum Werra-Meißner. The operation takes around three and a half hours, which is carried out with the so-called minimally invasive method. For this, small holes are cut into the abdominal wall. Through this, both instruments and cameras are pushed into the abdominal cavity so that the surgeon can operate by means of a probe and monitor. While Korenkov performs the procedure, senior physician Harald Günnel ensures that a light in a probe enough light falls into the operation area.

First, the abdominal cavity of the patient is filled with carbon dioxide. "It has the advantage that it is not a flammable gas and is well degraded by the body," explains surgical nurse David Dittrich. The gas lifts the abdominal wall. For the surgeon it has the advantage that they have more space and the organs are more accessible. The gas is released by the body during the following days.

With an electric cautery, a kind of medical curling iron, Korenkov cuts the fat off the stomach. This is then separated into a smaller and a larger part and closed with titanium clips. The separated larger part is thus shut down and remains in the body.

In the small remaining stomach Korenkov cuts a hole with the cautery. Then he measures the part of the duodenum - a part of the small intestine - which is to be shut down. As a rule, this is one and a half meters. In the intestine is also a hole cut with the cautery. The holes in the stomach and intestine are stacked and sealed with titanium clips.

Thereafter, the disused piece of intestine, which hangs on the also disused, larger piece of stomach, also connected to the intestine again. That's the hardest part of surgery, says Dittrich, because the gut is constantly moving. Therefore, Korenkov puts a suture on the contiguous bowel parts, so they do not slip away. And: "The deeper you go in the gut, the more fat is there," explains Korenkov.

Sits the seam, two intestinal loops have emerged. The digestive juices - that is, bile and pancreatic juice - run through a loop, and the other porridge comes out of the stomach. Both come together only when the intestinal loops meet. Only from there - and thus reduced - the body can absorb calories from the food pulp.

When all organs are connected, a blue liquid is injected into the new digestive tract. This will allow surgeons to see if everything is tightly sealed or if fluid is leaking at one point. It is also checked by monitor whether everything is connected correctly and, for example, the intestinal loops are correct. When everything is in place and the instruments are pulled out of the holes in the abdominal cavity, Korenkov and Günnel place drainage in some of the holes so that fluids can drain off.

The procedure took around three and a half hours and many patients hope for a decrease. However, the operation is only the beginning, say Korenkov and Günnel after the operation. According to this, it is the behavior of the patient, who by the way - a consequence of the lower nutrient intake - has to take vitamins for the rest of his life in order not to get any shortage.

Gastric bypass improves kidney function in Type 2 diabetics


Gastric bypass has positive effects on kidney function in patients with insulin-dependent diabetes mellitus type 2, which cannot be sufficiently controlled with drugs. Adrian T. Billeter and his co-authors speak of these findings in the current issue of the Deutsches Ärzteblatt medical journal. In a prospective cohort study, 20 patients with a Body Mass Index of 25-35 kg/m2 have undergone a standardized gastric bypass surgery (Roux-en-Y-gastric bypass). Before the operation and 12 and 24 months after the surgery, their blood and urine were sampled to evaluate the kidney function.

Kidney diseases or renal dysfunction (nephropathy) are the most common and most dangerous complications in patients with diabetes mellitus type 2 (DMT2). The prevalence is 20-40% of DMT2 patients. Many of those affected by diabetic nephropathy develop terminal renal insufficiency requiring dialysis. Strict blood sugar control alone does not improve nephropathy.

The gastric bypass reduced the glycolized hemoglobin (HbA1c) and the need for insulin in slightly obese patience with type 2 diabetes. After the operation the renal function improved. For example, serum creatinine levels dropped significantly and remained at a constantly low level for 24 months. For the authors, the gastric bypass represents a new treatment option, which could be effective even if the organ is already damaged. However, their study results still need to be confirmed by randomized controlled studies.

Gastric bypass is highly effective for at least 10 years


Approximately 23% of men and 24% of women in Germany have a BMI of ≥ 30 kg/m2 and are considered obese. Obesity is classified as morbid if the BMI ≥ 40 kg/m2 without comorbidity and BMI ≥ 35 kg/m2 with comorbidity. If other treatment methods do not bring satisfactory results, bariatric surgery may be an option. The possible procedures are Roux-Y-gastric bypass (RYGB), sleeve gastrectomy and adjustable gastric banding.

The various methods of bariatric surgery are significantly more effective in reducing body weight than non-surgical ones. In the first year, patients with Roux-Y gastric bypass lose more weight than patients with sleeve gastrectomy or gastric banding. The difference remains almost the same for over 4 years, although individual groups even show weight increase. The Roux-Y gastric bypass is highly effective even 10 years after the surgery.

"Impressively, the study demonstrates the long-term effectiveness of bariatric surgery for over 10 years in a large number of bypass patients compared to unoperated patients with similar comorbidity," comments Prof. Dr. med. Thomas P. Huettl and Dr. med. Otto Dietl, chief physicians at the Obesity Center Munich. "However, the patients with the bypass surgery are inhomogeneous compared to sleeve gastrectomy and gastric banding groups. Even so the superiority of gastric bypass surgery and sleeve gastrectomy compared to the gastric banding is now proven.“

However, data from prospective randomized studies differed from the results of the current study. In the first two years there was no difference in weight loss and remission of comorbidities between the patients with bypass and sleeve gastrectomy. "Both procedures, Roux-Y-gastric bypass and sleeve gastrectomy, must now be regarded as standard procedures," say Huettl and Dietl. The therapy choice is made individually, taking into account the BMI, comorbidities, medication and addictive drugs history, such as nicotine consumption, and patient wishes.

Long-lasting weight loss thanks to gastric bypass surgery


A long-term study shows the persistent effect of a Roux-en-Y gastric bypass. The study was performed by surgeons on obese patients. Ten years later most patients who had undergone surgery were able to maintain the achieved weight loss. Compared to other bariatric surgeries, patients after an Roux-en-Y gastric bypass achieved the greatest success.

573 people with a long history of obesity who had received a Roux-en-Y gastric bypass surgery were monitored for over ten years and compared with an unoperated control group. The group consisted of 1,274 highly obese people with a Body Mass Index of about 47 who did not receive any formal therapy against obesity. Almost every third person from the study group had Diabetes Type 2.

Ten years later, RYGB patients have lost 21% more weight. Only 19 out of 564 experienced the Jojo effect and almost returned to their initial weight after these ten years. The successful results after a Roux-en-Y gastric bypass surgery outweighed: ten years almost later 40% of the patients who had undergone the surgery were able to achieve a weight loss of 30%. In the control group, only 4% achieved this target. The authors explain that even without a therapy they could lose a few extra pounds due to age-related effects. One also cannot rule out that some individuals may have participated in a movement programme.

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