Obesity Surgery, 17, 1277-1278

César Roux and his Contribution The origins of “Roux” have been occasionally misinterpreted. A deposition from a legal case was sent to us in which the surgeon described “Roux” as meaning street (“rue”). César Roux (1857-1934) was born in Mont-laVille, Switzerland. He studied Medicine in Bern, receiving his degree in 1880. Dr. Roux eventually practiced in Lausanne, where he became chief of surgery at the Kantonsspital and Professor of External Pathology and Gynaecology at the newly founded University of Lausanne.1,2 Roux had wide interests in surgery, including the treatment goiter, pulmonary tuberculosis, and, in 1926, the first removal of a pheochromocytoma.3 A tragic problem in the 1890s was the slow death of patients suffering from gastric outlet obstruction from peptic ulcer disease or carcinoma. At that time, there was no radiology to provide a preoperative diagnosis, only an early concept of asepsis (with no rubber gloves), rudimentary anesthesia, and lack of I.V. fluids. Fluids were administered into the rectum (clysters), and oral fluids were started early postoperatively. Nevertheless, in 1892 for gastric outlet obstruction, Roux first performed his “ansa-en-Y” to bypass stomach. He divided the jejunum 15-30 cm distal to the ligament of Treitz, anastomosed the distal end (subsequently known as Roux limb) to the stomach, and anastomosed the proximal jejunal (afferent or biliopancreatic) end to the side of the jejunum 10-12 cm distal to the gastrojejunostomy. The gastrojejunal anastomosis was retrocolic to posterior stomach, and the opening in the transverse mesocolon was closed with sutures (Figures 1 A, B, C).4,5 Roux first reported this technique in 1893,4 and subsequently performed 116 of these operations.1,5,6 A

B

A

B

C

Figure 1. A. Identification of jejunum and posterior stomach. B. Termation of the Y. C. The retrocolic posterior gastro-jejunostomy en Y with mesenteric sutures. Reprinted from [4,5]. © Springer Science + Business Media, Inc.

A late complication of this operation was marginal ulcer on the jejunal side of the gastrojejunostomy, which eventually occurred in 50% of these patients.1 There was no pharmacological treatment for peptic ulcer and no concept of Roux with his charactervagotomy at the time. Thus, the César istic abundant mustache. Roux-en-Y jejunal loop fell into disuse, and is essentially omitted from the textbooks of the first half of the 20th Century (Orr, Thorek, Spivak, Shackelford). However, in the 1950s, the Roux-jejunal limb, with a 40-45 cm length, began to be used for several very important indications:7-9 1) relief of biliary obstruction due to either stricture or tumor; 2) drainage of the pancreatic duct of Wirsung for chronic pancreatitis; 3) internal dependent drainage of pseudocysts of the head of the pancreas; 4) the first-step in a staged Whipple procedure if longstanding biliary obstruction had been present; 5) treatment of choice for congenital choledochal cyst; 6) total gastrectomy stomach-substitution (esophago-Roux-jejunostomy); 7) complicated duodenal trauma; and 8) bile alkaline reflux gastritis and reflux esophagitis. The 40-45 cm Roux-limb prevented reflux of digestive juices into the stomach, and prevented reflux of food into the biliary-pancreatic system (avoiding ascending cholangitis). In bariatric surgery, the use of a Roux limb to drain the proximal stomach was first performed in 1977: Nicola Scopinaro with the biliopancreatic diversion10,11 overcame the blind loop of the jejuno-

Figure 2. A. JI bypass:12 long blind loop resulted in stasis, bacterial overgrowth and bloating. B. BPD of Scopinaro avoided stasis and has a long Roux (alimentary) limb.11 Obesity Surgery, 17, 2007

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César Roux A

B

Mason – 1967 Loop GBP

Griffen – 1977 RYGBP

Figure 3. A. Loop gastric bypass.15 B. Subsequent Rouxen-Y gastric bypass.14

ileal bypass12,13 (Figure 2); and Ward Griffen prevented tension on the jejunal in-continuity loop and bile reflux14 of the Mason horizontal loop gastric bypass15 (Figure 3). The main postoperative complication, found in 30% of patients with a Roux construction after partial gastrectomy, is the “Roux stasis syndrome” (abdominal pain, nausea, intermittent vomiting).16,17 This syndrome is possibly the result of gastric or Roux jejunal limb functional obstruction, an ectopic Roux-limb pacemaker, dysmotility from mesenteric neural interruption, or a location of bacterial overgrowth. However, after bariatric surgery the Roux syndrome is rare, possibly due to the small proximal gastric pouch. Gustavsson found that the Roux stasis syndrome is uncommon after total gastrectomy.17 In this issue of OBESITY SURGERY on Page 1408, Baltasar reports the use of a Roux limb as a remedial procedure for an esophagogastric junction fistula after sleeve gastrectomy.18 Mervyn Deitel, MD, Editor Toronto, Canada

References 1. Besson A. The Roux-Y loop in modern digestive tract surgery. Am J Surg 1985; 149: 656-64. 2. Mason GR. Perspectives a century later on the “ansa en Y” of César Roux. Am J Surg 1991; 161: 262-5.

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3. Who Named It? César Roux. www.whonamedit.com/doctor.cfm/3068.html (accessed July 9, 2007) 4. Roux C. Chirurgie gastrointestinale. Revue de Chirurgie 1893; 13: 402-3. 5. Roux C. De la gastro-entérostomie. Etude basee sur les opérations pratiquées du 21 juin 1888 au ler septembre 1896. Rev Gynec Chir Abdom 1897; 1: 67-122. 6. Roux C. Les anastomoses intestinales et gastrointestinales. Rev Gynec Chir Abdom 1900; 4: 787-96. 7. Puestow CB. Surgery of the Biliary Tract, Pancreas and Spleen, 3rd Edn. Chicago: Yearbook 1964: 223-7. 9. Richie JP Jr. Shackelford’s Surgery of Alimentary Tract, 3rd Edn, Vol II. Philadelphia: WB Saunders 1991: 177. 8. Holder TM. Choledochal cyst: management by Rouxen-Y jejunal drainage. In: Ellison EE, Friesen SR, Mulholland JH, eds. Current Surgical Management III. Philadelphia: WB Saunders 1965: 109-12. 10.Scopinaro N, Gianetta E, Civalleri D et al. Bilio-pancreatic by-pass for obesity: II. Initial experience in man. Br J Surg 1979; 66: 619-20. 11.Scopinaro N, Adami GF, Marinari GM et al. Biliopancreatic diversion: two decades of experience. In: Deitel M, ed. Surgery for the Morbidly Obese Patient. Toronto: FD-Communications 2000; 227-58. 12.De Wind LT, Payne JH. Intestinal bypass surgery for morbid obesity: long term results. JAMA 1976; 236: 2298-301. 13.Deitel M, Shahi B, Anand PK et al. Long-term outcome in a series of jejunoileal bypass patients. Obes Surg 1993; 3: 247-52. 14.Griffen WO, Young VL, Stevenson CC. A prospective comparison of gastric and jejunoileal bypass procedures for morbid obesity. Ann Surg 1977; 186: 500-9. 15.Mason EE, Ito I. Gastric bypass in obesity. Surg Clin North Am 1967; 47: 1345-54. 16.Mathias JR, Fernandez A, Sninsky CA et al. Nausea, vomiting and abdominal pain after Roux-en-Y anastomosis: motility of the jejunal limb. Gastroenterology 1895; 88: 101-7. 17.Gustavsson S, Ilstrup DM, Morrison P et al. Roux-Y stasis syndrome after gastrectomy. Am J Surg 1988; 155: 490-4. 18.Baltasar A, Bou R, Bengochea M et al. Use of a Roux limb to correct esophagogastric junction fistulas after sleeve gastrectomy. Obes Surg 2007; 17: 1408-10.