Roux Stasis Syndrome

What is a Roux-en-Y limb

After part or all of the stomach is removed, surgeons often reconnect the digestive tract with a Roux-en-Y configuration: a loop of jejunum (small intestine) is brought up to the remaining stomach or esophagus, creating a Y shape. This prevents bile from flowing back into the stomach and esophagus. It is used after gastrectomy for cancer or ulcers and in some other operations.

Why stasis happens

When the jejunum is divided to create the Roux limb, it is cut off from its natural pacemaker in the duodenum. Ectopic pacemakers in the limb can generate contractions that run backward, slowing transit. The stomach remnant may also empty poorly, particularly after vagus nerve cutting (vagotomy). Longer Roux limbs (over about 40 cm) are associated with higher risk.

Symptoms

• upper abdominal pain or discomfort after meals
• feeling full early
• bloating
• nausea and vomiting, often of undigested food
• loss of appetite
• weight loss and malnutrition in severe cases

Symptoms overlap with other post-gastrectomy problems, such as dumping syndrome, bile reflux, anastomotic narrowing, ulcers at the join, internal hernias and bowel obstruction. See postgastrectomy syndrome.

Diagnosis

The aim is to confirm slow emptying and rule out mechanical blockage:

• upper endoscopy: checks the join (anastomosis) for narrowing, ulcers or a bezoar (a mass of undigested food)
• CT scan or contrast X-ray studies: look for obstruction, internal hernia or dilated loops
• gastric emptying scintigraphy: measures how fast a test meal leaves the stomach remnant
• blood tests for nutrition, electrolytes and anemia

Treatment

Diet

• small, frequent meals, 5 to 6 a day
• chew well and eat slowly
• limit high-fat and high-fiber foods that slow emptying
• liquid nutrition supplements, which empty more easily than solids
• dietitian support

Medicines

• prokinetics: metoclopramide or erythromycin to stimulate gut movement, used with caution and monitoring for side effects
• anti-nausea medicines
• treatment of bacterial overgrowth if present
• vitamin and mineral supplements: B12, iron, calcium, vitamin D

Procedures and surgery

• endoscopic removal of bezoars and dilation of narrowed joins
• feeding tubes into the intestine beyond the Roux limb for severe malnutrition
• revision surgery: shortening the Roux limb, removing more of the stomach remnant (completion gastrectomy), or using an "uncut Roux" technique. Surgery helps many but not all patients

Outlook

Symptoms improve with diet and medicines in many people. A subset have persistent problems that need further surgery. Nutritional monitoring is important, as people after gastrectomy are at risk of deficiencies and weight loss.

Frequently asked questions

What is Roux stasis syndrome?

It is a condition after Roux-en-Y gastric surgery in which food passes too slowly through the stomach remnant and the Roux limb of intestine. It causes pain, fullness, nausea and vomiting after meals, and can lead to weight loss.

What causes Roux stasis syndrome?

Cutting the small intestine to create the Roux limb disconnects it from the gut's natural pacemaker, so contractions become disorganized or run backward. Poor emptying of the remaining stomach and long Roux limbs also contribute.

How is Roux stasis diagnosed?

Doctors use endoscopy and imaging to rule out blockages, ulcers and bezoars, and a gastric emptying study to confirm slow passage of food. Diagnosis is made when slow emptying is confirmed without a mechanical cause.

How is Roux stasis syndrome treated?

Treatment starts with small, frequent low-fat meals and liquid supplements, plus prokinetic medicines such as metoclopramide or erythromycin. Persistent cases may need endoscopic procedures, feeding tubes or revision surgery.

Does Roux stasis happen after gastric bypass for weight loss?

It is mainly described after gastrectomy with Roux-en-Y reconstruction. After weight-loss gastric bypass, similar symptoms are more often caused by narrowing at the join, ulcers, internal hernias or dumping syndrome, which should be investigated.