In a subset of super-obese patients, the one-stage laparoscopic Roux-en-Y gastric bypass (RYGBP) can be associated with significant morbidity and mortality. In a previous effort to reduce the perioperative risks associated with the super-obese, a two-stage operation was devised. This two-stage operation consisted of a sleeve gastrectomy (1st stage) followed by a RYGBP or duodenal switch procedure (2nd stage). We find that the primary limiting factor making laparoscopic gastric bypass challenging in the super-obese is the volume of the left lobe of the liver. A greatly thickened left lobe of the liver obscures visualization of the gastroesophageal junction and angle of His so that a sleeve gastrectomy is difficult to construct. In this report, we describe a novel method utilizing a staged Roux-en-Y procedure. Instead of performing a restrictive operation (sleeve gastrectomy) as the initial procedure, we fashion a modified Roux-en-Y with a low gastrojejunal anastomosis and a larger gastric pouch encompassing the gastric fundus. The low anastomosis obviates the need for exposure of the gastro-esophageal junction and angle of His. At the 2nd stage procedure, completion sleeve gastrectomy of the gastric fundus is performed at an interval of 6-12 months after the 1st stage operation.

Gastrointestinal hemorrhage is a potential perioperative complication after Roux-en-Y gastric bypass. The surgeon performing laparoscopic gastric bypass should understand the need for early recognition and management of this complication, as it can be life-threatening. This paper discusses the incidence and clinical presentation of gastrointestinal hemorrhage, mechanisms for hemorrhage, management options, and possible methods of prevention.