Obesity Defined

There is need for more research in the field of obesity. Until a time when a less invasive, effective, non-surgical treatment is available, surgery offers the only long-term control of obesity. Surgery should not be considered as the last resort because, at this time, it is the only effective resort. Obesity is a hereditary disease. The exact method of genetic transmission is not known. The expression of obesity varies with social, environmental, cultural, economic, and psychological influences.

Obesity may be caused by a glandular or hormonal imbalance, but affects less than 2% of the obese population. Rarely is obesity due to an eating disorder. It is highly probable that the obese person with eating disorders has the disorder as a result of the frustration or associated problems of obesity. Obesity is definitely not caused by a lack of willpower. Obesity is not a psychological or psychiatric disorder.

On the contrary, obesity may predispose to psychological or psychiatric disorders.

Complications of Obesity

The multitude and severity of complications are all directly proportional to the severity and duration of obesity and vary with the distribution of body fat. A. Medical Complications:Diabetes, Hypertension, Gallbladder disease, Gastrointestinal Disorders, Menstrual Irregularities, Degenerative arthritis, Venous Stasis Ulcers, Pulmonary Hypoventilation Syndrome, Sleep Apnea, Snoring, Coronary Artery Disease, Arterial Sclerotic Disease, Increased Incidence of Malignancies (ovaries, cervix, uterus, breast, prostate, gallbladder), Increased Risks with Surgery, Accident Proneness, Pseudo tumor Cerebri. B. Social ComplicationsClothing Limitations, Movement Limitations (can lead to inability to maintain hygiene), Limited Access to chairs and passageways, Limitations to Walking and Climbing, Sexual Limitations. C. Economic ComplicationsTotal cost of obesity and related problems is over $100 billion a year in the United States. Cost of Futile Weight Loss Modalities, Cost of Treatment of Medical Complications, Increased Costs of Health Insurance Premiums, Job Discrimination, Costs of Special Clothing or Devices to overcompensate for limitations. D. Psychiatric Complications

Depression, Social Withdrawal, Neurotic Disorders, Guilt, Self Hate, Feelings of Hopelessness and Helplessness, Suicide Risk.

Surgical Treatment of Obesity

1. Gastric Bypass: Gold standard for obesity surgical treatment > 80% success with > 40% excess weight loss maintained for more than 5 years. Mortality of < 1% and morbidity of < 10%. Long-term complications include deficiencies of Iron, Calcium, Fat-soluble Vitamins A, D and E and Vitamin B12, Folic Acid and B1 and B6. Anemia is seen mostly in menstruating individuals. There are various modifications of the gastric bypass operation. The Fobi-Pouch, one of the modifications, has excellent weight loss, acceptable complications and revision rate, and well tolerated by most of the patients. 2. Gastroplasty: A simple common operation for control of obesity. About 60% success rate with > 40% excess weight loss maintained for more than 5 years. Mortality rate of < 1% with morbidity of < 10%. High revision rate due to staple line breakdown that approaches 28% over a five-year period. No long-term nutritional complications characteristic of this operation. Vertical banded gastroplasty (VBG) and silastic ring vertical gastroplasty (SRVG) are the two most common gastroplasty operations performed. 3. Other operations:

• Biliopancreatic Diversion (BPD)Gastric Banding (GB) -- investigationalIntestinal Bypass (JB) -- not recommendedBiliopancreatic Diversion with the Duodenal Switch
• Distal Roux-Y Gastric Bypass

The Fobi-Pouch for Obesity

The Transected Vertical Gastric Bypass with a Silastic Ring Band and a gastrostomy with a gastrostomy site marker, popularly known as the "Fobi-Pouch Operation for Obesity" is not a new operation. It is a modification of an operation, over a hundred years old, now applied to the management of the severe recalcitrant medical problem of obesity. The "Fobi-Pouch Operation for Obesity" has an operative mortality of < 1% and significant morbidity of < 10%. It is 95% effective with greater than 40% excess weight loss that is maintained for more than five years of follow up. Long term related complications include Fat-soluble vitamin deficiencies, Calcium, Iron, B12, and Folic Acid deficiencies with the resultant osteoporosis and anemia. All of these can either be prevented or corrected. There may be problems with vomiting, dumping, hypoglycemia, dizziness, loose stools, nausea, and certain food intolerance. The Fobi Pouch Gastric Bypass consists of a less than 30 cc pouch of the proximal stomach on the lesser curvature, a silastic ring around the stomach that functions as a stoma. The band is 5.5 - 6.5 cm long. A gastroenterostomy to a Roux-y limb of the jejunum completes the operation. A gastrostomy tube is placed to decompress the bypassed stomach postoperatively. The gastrostomy site has a silastic ring marker to facilitate percutaneous access for radiological and other evaluations of the bypassed stomach if the need arises.

The Fobi Pouch Gastric Bypass has the following significant characteristics:

1. Vertical < 30 cc pouch
Easy to intubate, less distensible, provides early satiety. 2. Transected Pouch
Minimal mobilization, no problem with staple line breakdown, minimal occurrence of marginal ulcers. 3. Banded pouch, longer band, 5.5 - 6.5 cm
Leaves a large stoma - but limited in diameter, allows dumping -- but not severe dumping. Prevents stomal dilatation. 4. Imbricated Gastrojejunostomy
The limb of the jejunum that is brought up to form the gastroenterostomy is also used to imbricate the transected edge of the proximal pouch thus diminishing the possibility of leaks and subphrenic abscess. 5. Large gastroenterostomy 1.5 - 2 cm long
Markedly decreased rate of gastric outlet stenosis 6. Decompressed distal gastric pouch with a gastrostomy
No incidence of acute gastric distension, decreased incidence of atelectasis, provides for temporary feeding and administration of medication if the need does arise. 7. Gastrostomy site marker
Provides easy access to study distal bypassed stomach radiologically and/or endoscopically, as needed, access for enteral feeding in the rare case of excessive weight loss. The only foreseeable nutritional complications from this operation are Vitamins A, B1, B12, D and E, Calcium, Iron, and Folic Acid deficiencies and the associated osteoporosis, anemia, and other conditions. These problems are preventable and correctable.

Areas of Concern With the Use of the Gastric Bypass by Many in the Field of Obesity are Now Adequately Resolved by the "Fobi-Pouch Operation for Obesity" (FPO)

These are: 1. Acute gastric distention with or without perforation.
The routine use of a temporary gastrostomy as part of FPO has eliminated this complication as a concern in the gastric bypass operation. (3% to 0% in our last 1000+ patients). 2. Leaks
Leaks have been minimized in the FPO. The imbrication of the proximal pouch with the Roux-Y Limb has significantly reduced the incidence of leaks with intra-abdominal abscess. The band above the gastrojejunal anastomosis has also significantly reduced the incidence of breakdown at the gastrojejunal anastomosis. The use of a selective protocol of using the gastrostomy feeding channel in certain patients undergoing revision operations and keeping the patients without any oral intake for 3 days to two weeks have significantly reduced the incidence of leaks in revision operations. Direct visualization of the anterior and posterior aspect of the pouch also allows easy diagnosis of intraoperative traumatic complications. 3. Pouch Size and Measurements
Direct visualization of the transected pouch's anterior and posterior surface allows the surgeon to have a better control on the pouch size. 4. Closed Loop Obstruction
Admittedly, the incidence of bowel obstruction after the gastric bypass operation is higher than after the gastric banding or vertical banded gastroplasty just because the nature of this operation involves the small bowel. The incidence of closed loop and internal hernia obstructions, are reduced in the FPO by:a. Closing the mesenteric gap at the jejunojejunal anastomosis; b. Placing an anti-kinking suture at the jejunojejunal anastomosis; c. Closing the gap between the mesentery of the Roux-Y Limb and the posterior peritoneum and the mesocolon.

• Access to the bypassed gastric segment
  The marked gastrostomy site in the FPO provides ready access to the bypassed gastric segment for radiological and endoscopic evaluation. Access to this segment for feeding purposes in cases of rapid weight loss, problems with the gastric outlet, or in the rare case of protein malnutrition, is also facilitated by the marked gastrostomy site. Difficult Operation
  The FPO operating time, in experienced hands, is about double the time that a vertical banded gastroplasty operation takes. The Perioperative complications in series of more than one thousand patients are around 10%. However, the significant difference in the amount of weight loss and the low revision rate with the associated morbidity seen in revisions, make the FPO a much more desirable operation than any of the restrictive operations.
• Micronutrient deficiencies (i.e. Vitamins A, B1, B12, D and E, Folic Acid, Iron, Calcium and the associated conditions.)

Information on these deficiencies is given to the patients and they are placed on nutritional supplements for the rest of their lives. Yearly monitoring is required.

Protocol for Fobi-Pouch Surgery

Four days hospitalization consisting of an AM surgery admission with discharge in four days. Follow up is at seven to ten days, six weeks, three months, six months and yearly thereafter. Preoperative work-up may include CBC, SMA 22, Thyroid profile, Hepatitis panel, EKG, CXR, GB ultrasound, UGI series, Body Composition, treadmill evaluation, esophagogastroduodenal endoscopy and other tests as may be deemed necessary by the patient's condition. A specialized team is used for management of patients, consisting of an anesthesiologist, scrub nurse, circulating nurse, patient counselor, cardiologist, pulmonary specialist and surgeons. Other consultants are called preoperatively and/or postoperatively, as deemed necessary. Psychiatric disorders have not been found to be a contraindication for the procedure. Patients with a history of psychiatric problems are cleared for surgery by a consulting psychiatrist. Selection of patients for this operation is based on the simple surgical policy of assessing the risk benefit ratio. All patients have stomach X-rays within two weeks after the operation. Stomach X-rays are planned for the first year and as necessary thereafter. Radiographic evaluation of the distal bypassed stomach is recommended every five years after age 50.