Roux-en-Y gastric bypass is widely considered the gold standard in bariatric surgery, resulting in the largest long-term excess-weight loss of any comparable procedure. RYGB is complex and difficult to perform, and it used to require a one-day to three-day hospital stay. But today, laparoscopic techniques, better anesthesia regimens and more effective pain control have let us considerably shorten recovery times and increase the procedure's overall effectiveness.

At Baylor University Medical Center, we have four surgeons who perform RYGB on more than 1,000 patients each year. What's remarkable about our program, besides our high case volume, is that almost 75 percent of our patients leave within 23 hours of surgery. In this article, I'll describe the surgical process and share how we're breaking the inpatient barrier for gastric bypass.

Our team and facility
Our four surgeons are highly experienced in laparoscopic RYGB, which requires extensive training in general laparoscopic surgery and a minimum of 50 laparoscopic RYGB cases to achieve proficiency (I had done 300 open procedures and 100 inpatient laparoscopic RYGB cases before attempting my first 23-hour case).

We perform all procedures at the Baylor University Medical Center, a 700-bed acute-care hospital. We also have an off-campus center for pre-op and long-term post-op care where patients have their initial consultations, undergo pre-op testing and participate in support groups. Our team includes a psychologist and psychiatrist, two dietitians and several support staff.

The pre-op process
We hold information seminars every two weeks that attract about 150 prospective patients. During the seminars, we discuss every part of the procedure - including the substantial lifestyle changes required for a successful outcome. We stress that this isn't a magic bullet for weight loss, but most people have researched the procedure beforehand and have realistic expectations. About 70 percent of the seminar participants elect to go through with the procedure.

Prospective patients go through a battery of tests and consultations, including a psychological screening, EKG, chest X-ray, routine bloodwork and an echocardiogram, if needed. During the screening process, we also target the patients who aren't eligible for the outpatient procedure. Patients older than 56 years who have a BMI greater than 60 and weigh more than 400 pounds generally have to stay in the hospital longer than 23 hours.

After we receive approval from a patient's insurance company (this takes anywhere from a week to six months), there's usually a four-week to eight-week wait before surgery. During this time, many patients participate in a pre-op support group run by a nurse who has had the procedure. Pre-op support helps patients deal with any doubts, prepare physically and mentally and resist the impulse to gain more weight.

The procedure
On our surgery days, we set up two ORs and two operating teams, so the surgeon can go seamlessly from one case to the other, completing about 12 per day.

The surgery requires four or five incisions, lasts about an hour and is fairly complex. First, we create a proximal stomach pouch, which holds about 30ccs. We then divide the upper jejunum, bring it in front of the colon (an antecolic approach) and connect it to the stomach pouch (this section of the intestine is called the Roux limb). We connect the end of the jejunum to the side of the Roux limb.

Food therefore passes through the esophagus, into the upper pouch, through the anastamosis and into the Roux limb. Digestive juices from the stomach, liver and pancreas pass through the duodenum and the jejunum, mixing with the food in the Roux limb, where the parts of the small intestine are attached. The food and the digestive juices then pass through the rest of the intestine.

Over the years, we've modified the procedure in the following ways to reduce the risk of complications, ensure a smooth short-term recovery and increase the chances of long-term success:

• Pain and PONV control. After a propofol induction, we administer prophylactic antibiotics and a Decadron bolus, which reduces and sometimes eliminates post-op nausea and vomiting. Thirty minutes before the end of the case, we start a Precedex drip, which we continue for at least two hours post-op. This greatly reduces the need for post-op narcotics, which in turn diminishes the risk of sleep apnea. We also insert an On-Q pump, which provides a continuous infusion of local anesthetic to the incision site; we remove it before the patient leaves the hospital.
• Surgical technique. We've found that the retrocolic approach, although it provides a shorter pathway for the Roux limb, results in internal hernias in about 4 percent of patients. After we switched to an antecolic approach, the incidence dropped to 0.1 percent. Our bowel obstruction rate also dropped to 0.5 percent. Gastric staple-line failures are a potentially lethal complication, so we use Peri-strips to buttress the staple line; our staple-line failure rate dropped from 3 percent to 0.01 percent. By switching from 21mm to 25mm circular staples, we've reduced the rate of gastro-jejunal anastomotic strictures, which typically develop three weeks to six weeks post-op, from 7 percent to 0.8 percent. And we do intraoperative leak testing leaks at the gastro-jejunal anastamosis with a methylene blue dye solution.

The post-op period
To prevent DVTs and pulmonary embolism, which are common in obese patients, we administer low molecular-weight heparin as soon as patients enter Phase I recovery. Patients with a BMI over 60 take heparin for 10 days.

Patients usually experience much less pain and nausea than they were expecting, which is a testament to the effectiveness of the Precedex drip and the On-Q pump. We also offer PCA pumps for backup pain control, but only half our patients need them. We also offer PRN Anzemet for PONV. About 30 percent of patients experience mild nausea, 2 percent experience severe nausea and only about 1 percent experience vomiting.

Two hours to four hours after patients enter Phase I recovery, they are moved to a private room, where they start walking and drinking liquids. They usually recover for about 20 hours. When they're ambulating, without fever, are tolerating liquids, have minimal pain and exhibit stable vital signs, they're ready to leave. They're given extensive post-op instructions and told to call their surgeon if they experience problems in the immediate post-op period. So far, our re-admission rate has been 1.6 percent.

Patients return for post-op visits at two weeks, six weeks, six months and a year (follow-up rate is 100 percent). We also offer plenty of ancillary support, including an online support group, which is moderated by surgeons and program staff and gets about 3,000 posts a month.

Our results
Our weight-loss surgery program has been a success for both our patients and the hospital. Our patients average 75 percent excess-weight loss at two years, and our case volume has grown almost exclusively through word of mouth from satisfied customers. Here are some other successes we've achieved as a result of doing RYGB as an outpatient procedure:

• Our wound-infection and pulmonary-complication rates are less than 1 percent.
• Patients generally return to work two weeks post-op.
• We've improved surgeon efficiency and achieved high nursing satisfaction, which has led to more efficient use of hospital resources, which in turn has facilitated high volumes.

Performing RYGB as an outpatient procedure has markedly improved hospital revenues, allowing us to expand the bariatric services we offer. Because the demand is so high, and because more insurers and Medicare are classifying obesity as a disease, we expect our program to expand even further in the coming years - in fact, another surgeon recently came on board last month. As we gain more experience and as technology advances, we anticipate that our surgical times and recovery periods will further decrease, making the procedure even more accessible for prospective patients.