1. What is the Banded Gastric Bypass?
It is a modification of the gastric bypass procedure for treatment of obesity. It has a transected vertical gastric pouch. A silastic ring band is put around the gastric pouch to form an externally reinforced stomach. The Jejunal Limb (small bowel) is used as a patch to the cut edge of the pouch to minimize the incidence of postoperative leaks. A temporary gastrostomy tube is used to decompress the bypassed stomach/and a gastrostomy site marker is placed to facilitate future access to the bypassed stomach.

2. How small is the pouch?
The pouch is usually 15-30cc, less than 1 ounce or 1-2 tablespoonfuls.

3. Can the pouch stretch?
Yes, but not significantly except if abused by frequent vomiting or overeating.

4. Why is the silastic ring band used?
We, at The Center for Surgical Treatment of Obesity at St. Mary Medical Center, and others who have performed thousands of gastric bypass operations without the band have documented that the opening from the stomach pouch does stretch in some patients over time and allows the patient to eat more, thus regaining some of the weight that has been lost. The band controls the emptying of the pouch and helps to maintain weight loss. This band has been used in thousands of patients who had the silastic ring gastroplasty. Some surgeons use different material instead of silastic ring. It is an external reinforcement to the stoma.

5. How often do you have problems with the band?
Band erosion has been documented in less than 2% of patients. Band erosion is a treatable problem. An eroded band if left alone will extrude spontaneously or it can be removed by endoscopy. Rarely is surgical intervention needed for removal of an eroded band.

6. What happens if the band is removed?
The band controls the stoma in patients who would have stomal dilation and subsequent weight gain. Removal of the band for those patients may cause some weight gain. In some patients, however, the removal of the band has no consequences.

7. Can the band be replaced after removal?
Yes. However, the chance of the band erosion and complications of surgery is higher in revision operations and secondary operations.

8. How will I know the band is eroded?
Some patients with band erosion do not know and cannot tell. Some patients may have discomfort or pain under the breastbone when swallowing. Others may experience pain when drinking or eating, vomiting and/or solid food intolerance, which may be followed by the ability to eat larger quantities with weight gain. Band erosion is best diagnosed by endoscopic examination (An examination where a scope is passed through the patients mouth into his or her swallowing pipe and into the pouch to evaluate the pouch and the opening).

9. Can a patient request to have a Gastric Bypass without a band?
Yes. In that case it is not ‘The Fobi Pouch’. It is a regular Roux-en-Y Gastric Bypass. In most patients 65 years or older, the band may not be
used.

10. Why is a gastrostomy tube (G-tube) used?
The G-tube is used decompress the stomach in the immediate post-operative period and for feeding as the need arises. This prevents acute gastric distention and is an adequate substitute for the naso-gastric tube.

11. When is the gastrostomy tube removed?
Unless there is a medical reason, the gastrostomy tube is removed 7-10 days after surgery.

12. Why is there a gastrostomy site marker?
This marker facilitates access to the bypassed stomach for x-rays, endoscopic evaluation and feedings if the need arises.

13. What happens to the stomach that is bypassed?
It remains attached to the neighboring organs. The acid and fluid secretions are significantly decreased. It does not have the digestive function but can be used when there is a need for reversal or supplemental feeding.

14. What is the difference between The Fobi Pouch and the Roux-en-Y gastric bypass?
The Fobi Pouch is a Roux-en-Y gastric bypass with a band. (see diagram 2). The scientific name for The Fobi Pouch is the Vertically Transected, Silastic Ring Banded, Roux-en-Y Gastric Bypass with the Gastrostomy and the Gastrostomy Site Marker (TSRBVGB).

15. What is the success rate of The FOBI POUCH ?
It is 90% effective with greater than 50% excess weight loss that is maintained for more than five (5) years of follow up.

16. How rapid is the weight loss?
Most of the weight loss occurs in the first six (6) months. Weight loss has been known to progress for up to two (2) years. Frequent exercise and increased activities enhance weight loss.

17. Is such a rapid weight loss dangerous?
Usually not. Patients should take vitamin and mineral supplements after surgery for the duration of their life. Blood tests are obtained periodically to monitor blood chemistry and nutritional status.

18. How old was the youngest patient who has had The FOBI-POUCH?
12 years old.

19. Are staples used in this operation?
Yes, staplers are used for cutting and sewing the stomach and the small bowel fast and precisely. Clips are also used to control bleeding. However, this is not the gastric stapling operation.

20. Is the surgery painful?
Pain is a subjective feeling. Some patients say it was painful and others say it was not. Attend a Support Group Meeting and talk directly with patients who have had the surgery.

21. How long does an uncomplicated FOBI POUCH OPERATION take?
Two and one half (2.5) hours for open operation and it may take three (3) to seven (7) hours if done laparoscopically or if a panniculectomy is done at the same time.

22. Can other operations be performed at the time of the FOBI POUCH operation?
Yes. Cholecystectomy, tubal ligation, removal of ovarian cyst, ventral and umbilical hernia repair and panniculectomy are some of the procedures that can be performed at the time of the FOBI POUCH or Roux en Y GASTRIC BYPASS. Additional operations increase operating time, cost and may increase the risk of the operation.

23. Does this surgery require blood transfusion?
Typically no. However, with any surgery, there is a chance of having a transfusion if the need arises. Patients can have their own blood stored prior to surgery, to be used in the event of need.

24. How long is the scar?
The length of the scar depends on the different approaches for FOBI POUCH GASTRIC BYPASS. The patient will have an upper midline vertical scar from below the breastbone to just above the belly button in the standard open approach. If you have a panniculectomy with FOBI POUCH GASTRIC BYPASS, the scar is horizontal (bikini cut) from the left hip to the right hip. If you have laparoscopic FOBI POUCH GASTRIC BYPASS, you will have six to seven small scars (See diagram 3).

25. Is there anything I can do to reduce the appearance of the scar?
Leave the tapes (steri-strips) on your incision as long as possible. Some patients have used vitamin E gel-caps or cream to help the scar to heal better.

26. Who will be a candidate for FOBI POUCH GASTRIC BYPASS with panniculectomy or laparoscopic FOBI POUCH GASTRIC BYPASS?
By your request, but some of you may not have a particular approach for FOBI POUCH GASTRIC BYPASS. You can discuss your choice with the your surgeon at your initial consultation and the surgeon will suggest which approach will be best for you. Currently 90% of our patients undergo the laparoscopic Fobi Pouch Gastric Bypass.

27. How long is the recovery?
The duration of the recovery depends on the approach for FOBI POUCH GASTRIC BYPASS. Most patients completely recover in six (6) weeks after open approaches and in two to three (2-3) weeks after laparoscopic approach. No strenuous activities are advised during this recovery phase.

28. When can I go back to work?
If you have a non-strenuous job, you can go back to work in two to three (2-3) weeks after open approaches with the approval of the Surgeon. Most patients can resume regular activities in six (6) weeks after open surgery and within two to three (2-3) weeks after laparoscopic surgery.

29. What can I eat after surgery?
Most patients can eat anything. Just remember to chew, chew, and chew. Some patients cannot tolerate certain foods they used to eat before surgery. Each individual is different. It is recommended that patients stay on pureed foods for the first four to six (4-6) weeks. If a certain food does not agree with you, leave it and try it again months later.

30. How often do Fobi Pouch patients need to eat a day?
A typical patient may eat four to five times during first few weeks after surgery but it is recommended to eat only three meals a day. They will be able to eat only small amounts during the first few months after surgery, and it is recommended to consume large amounts of liquid after surgery, especially during first six months. It is also recommended not to skip a meal to avoid episodes of hypoglycemia (low blood sugar).

31. Am I really going to be able to eat only a tablespoonful of food at a time?
No. The pouch may hold a tablespoonful of food at a time, but you will be able to eat more than that. As time passes, you will be able to eat more because you have learned how to eat and chew properly. However, If you force yourself to eat, the pouch may stretch and you may be able to eat a whole meal with subsequent weight gain. Your typical meal will be about a quarter of what you used to eat before surgery.

32. What happens if I eat too much?
You will regurgitate food. You can tell when you start to feel full, and that’s when you should stop eating. As explained above, you will be able to eat more as you learn to chew and what to eat regardless of your eating pattern. Once you reach the point where you can eat comfortably about a quarter of what you used to eat before the surgery, try to stick to that size all the time. It can be achieved without struggle because of the band around pouch.

33. Can I drink alcohol or smoke after surgery?
We strongly recommend that you do not. An occasional glass of wine may be harmless and may have some merit. Your blood alcohol level may go much higher after surgery if you consume just a small amount of alcohol, and sometimes it may reach a toxic level that can damage your liver. You have to stop smoking completely after surgery. Smoking is one of the most common causes of marginal ulcer (ulcer around the area where the small intestine is connected to the pouch) and the ulcer may not heal unless the patient stops smoking.

34. Can I eat and drink at the same time?
You may, but it is not recommended. If you do that, water will be regurgitated quite often. You may regurgitate water if you drink fast, even without eating. Drink between meals.

35. Can I drink eight (8) glasses of fluids a day as recommended for other people?
Yes. We recommend drinking between meals in quantities enough to quench your thirst. Most patients have learned to carry a water bottle and take sips between meals. If you do not take enough fluid, you may develop dehydration and occasional kidney infection.

36. What is the popcorn test?
Some patients think they are plugged up or the opening out of the pouch is too small when they regurgitate food or liquid. Patients may vomit or regurgitate when they eat or drink too fast, do not chew adequately before swallowing or there are mechanical (anatomical) problems with the operation. To differentiate the causes of vomiting or regurgitation, patients are advised to eat some popcorn. If the patient eats the popcorn without regurgitation or vomiting, it is very unlikely that there is any mechanical obstructive problem with the operation. The patient is either eating too fast, chewing inadequately or swallowing large quantities at a time. This test is based on the premises that popcorn can only be swallowed after chewing well and only in small quantities at a time.

37. How did the popcorn test come about?
When Dr. Fobi was performing gastroplasty operations in early 1980s, he observed patients who would vomit after eating or drinking any type of food or liquid but not after eating popcorn. These patients had normal stomas radiologically and endoscopically but presented with symptoms of outlet stenosis. These patients either ate too fast, did not chew the foods well, gulped their drinks or did not respond to the feeling of satiety during eating. These patients were best treated not surgically but by counseling.

38. How much weight can one expect to lose?
Weight loss varies depending on the before-surgery weight, choice of food, level of activity after surgery and the metabolism of the particular patient. Most patient lose one-third (1/3) of their original weight within two years after surgery. The outcome results from our Center shows 90% of the patients lost at least more than 50% of the excess weight and kept it off during a five (5) year period.

39. Can one’s family doctor do pre-operative evaluation?
Yes. That can be arranged through the office. We insist that your primary care physician be part of your care before and after the surgery.

40. What are possible complications of the FOBI POUCH GASTRIC BYPASS?
vomiting, watery stools, difficulty breathing without a respirator, back pain, numbness, nerve and muscle injuries, difficulty passing urine, outlet obstruction, drainage from wound, wound dehiscence, bed ulcers and bowel obstruction.

Long term related complications include, but are not limited to, hair loss, depression, outlet stenosis, band erosion, gastro-gastric fistula, bowel obstruction, ventral hernias, cholelithiasis, hair thinning, inadequate weight loss, anorexia with excessive weight loss, fat soluble vitamin (A, D, E) deficiencies, calcium deficiency, iron deficiency, thiamine deficiency, vitamin B12 deficiency, folic acid deficiency, osteoporosis, anemia, dumping, diarrhea and hypoglycemia. These nutrient deficiencies can either be prevented or corrected.

41. Is hair loss common?
Yes. Any time you go through rapid weight loss, you can experience hair loss. Interestingly, some patients do not experience this at all. This is a temporary problem. It usually occurs during the third through eighteenth month after surgery, and then the hair growth returns to normal.

42. Is there anything I can take to prevent or minimize hair loss?
Try Biotin and zinc and increase protein intake. Some patients have
benefited from the use of Minoxidil (Rogaine).

43. What is dumping?
Dumping is a physiologic reaction that can occur after eating certain foods or drinking certain liquids. You may hear or feel your heart pounding, feel nauseous, feel clammy, feel dizzy and/or sleepy, become sweaty, shaky, have abdominal cramps or have diarrhea. Any combination of these symptoms can occur usually within thirty (30) minutes after eating or drinking. Sugar, grease and some dairy products such as regular milk or ice cream may cause dumping. Any high caloric liquid can cause dumping. If you take large amounts of starch and liquid at the same time, you may have dumping. Some patients experience dumping after drinking soft drinks and some juices. Try to avoid sweets, cut down the intake of starch and increase the intake of protein.

44. What do I do when I have dumping?
Sit or lay down. It normally goes away in less than thirty (30) minutes. Make a note of what you just drank or ate. After several episodes of dumping, you will be able to tell what foods or drinks to avoid.

45. What is a hypoglycemic attack?
It is due to low blood sugar level and similar to the dumping syndrome in expression. Mainly you will feel light-headedness and have a rapid heart beat. You may feel nauseous, shaky, clammy and sweaty. However, abdominal cramps and the urge to go to the bathroom are unusual. The attack usually occurs a few hours after meals or when the interval between meals is too long. The best treatment is prevention by eating regularly a high protein and low carbohydrate (rice, wheat, potato and corn products) diet. You may carry some cookies to ingest when you have feelings of getting the attack.

46. Is there anything I can do to prevent hanging skin after weight loss?
Exercise may help. However, if you lose an excessive amount of weight, more than likely you will have hanging skin.

47. Why do some patients have saggy skin and others not?
It depends on how much weight you lost, how elastic your skin is, how long you had been overweight and your age.

48. What is abdominal panniculectomy?
Removal of the abdominal apron or the removal of the extra skin and fat that hangs over your pubic area (pubic panniculectomy). Plastic surgeons may call it an abdominoplasty.

49. Who would qualify to get a panniculectomy?
It is usually based on the grade of the panniculus, patient’s wishes and patient’s medical condition.

50. Why is there so much phlegm or mucus build-up after the gastric bypass operation?
Usually you will experience this in the morning when you wake up. Also, if you are not eating often enough during the day, you may experience mucus build up. This will decrease after the first year of surgery. Even though you cannot eat much after surgery, your salivary glands continue to secrete large amounts of mucus. The mucus is unused and accumulates in the esophagus it then comes up as phlegm.

51. Will I vomit or have diarrhea after the GASTRIC BYPASS?
These are not the expected outcomes, but they do occur. Call the Counselor if you experience vomiting or diarrhea frequently. Certain food can cause diarrhea. Yes, you can still vomit if, for example, you are sick, eat too fast or swallow poorly chewed foods.

52. When I get ill and vomit, do I vomit acid and/or bile like other people?
No. In this operation the stomach and the area where the bile empties to the bowel is bypassed. You will probably have the dry heaves. If you vomit bile or acid, it is a bad sign and you should contact the surgeon or your doctor immediately.

53. Do I have to take vitamins for the rest of my life?
Yes. It is highly recommended.

54. What vitamins and minerals should I take and why?
Vitamin A, D, E, B6, B12, B1 (thiamine) iron, calcium and a multivitamin. The reasons are 1) because your intake is small and 2) because most of the stomach and part of intestine essential for absorbing some of these vitamins and minerals are bypassed.

55. Do I need to crush my pills?
Not necessarily. That may depend on the size of a pill. Some patients can swallow pills whole. If it is too big, you can crush or cut it in small pieces to swallow.

56. Can I buy vitamins from regular stores or does it have to be from a Pharmacy?
You can purchase them at any drug store. Just make sure they’re the same types of vitamins and the same quantity as recommended by your surgeon.

57. What happens if I don’t take vitamins?
You can have vitamin deficiencies. These include neurological alterations, anemia, skin changes, osteoporosis, bone pain and other metabolic abnormalities. These are difficult to diagnose and may take time to correct. Vitamins, calcium and iron supplements should be taken for life after this operation or any other type of gastric bypass surgery.

58. Will my sex drive change?
Yes. Some patients in the first two (2) years will have a decrease in their sex drive. However, some say their sex drive is higher.

59. Can one get pregnant and have children after this surgery?
Yes, barring no other fertility problems. It is recommended that patients after gastric bypass surgery wait at least one (1) year after the operation to get pregnant.

60. Why do some patients experience depression after this surgery?
Mostly due to unrealistic expectations of the outcome of the operation. The Support Group Meetings help patients through these difficult times. Occasional patients will need psychiatric consultation. The psychotherapist is always available to you if you think you are getting depressed.

61. Will I ever regain my weight?
The operation is only a tool to use to control your weight. If you do not use it correctly, you will regain some and possibly all of the weight that you lost.

62. What is the follow-up routine after gastric bypass surgery?
Usually patients are scheduled for a follow-up office visit between 7-10 days after surgery, then again at 6 weeks, 3 months, 6 months, one year after the surgery and yearly thereafter. You can make appointments to be seen at intervals more frequently if needed. If your appointment is too distant for your needs, we allow walk-in patients if you feel there is a need to see a doctor. As a walk-in patient, you might have to wait to be seen, but you will be seen.

63. Do out of state patients need to come back for checkup at the Center?
It would be ideal to come back for a checkup at least once a year, but it is not absolutely necessary. We strongly recommend that patients make follow-up appointments with their primary care physician in their town or city. We require all patients to have a primary doctor with whom their care will be coordinated.

64. Will I need a second operation?
Not necessarily. A second operation may be necessary because of complications. However, some patients seek reconstructive operations after weight loss.

65. Why do patients have revisions?
Revision operations are due to complications such as outlet problems, fistulas, too much weight loss, not enough weight loss, and band erosion. About 5% of patients a year may need revisional operations.

66. Why do I have to attend a Support Group Meeting before surgery?
To learn more about the surgery and to talk to other patients about their experiences. A picture is worth more than a thousand words. It makes you a better informed patient and facilitates your care. It is highly advisable to bring your friends and family members with you to these meetings. When you know more about the surgery, your outcome after the surgery will be better.

67. Is there a waiting list to have surgery?
Yes. We are booked at least one (1) month in advance. However, if there is a reason why you need to have surgery by a certain date, it can be discussed with the Scheduling Manager. There is an obligatory waiting period of ten (10) working days between the Session attendance and the surgery.

68. How long does it take from the time I decide to have surgery to the scheduled date of surgery?
It depends. After the initial informational session, you need to have a consultation with the surgeon and other consultants. After the
consultations, a prior authorization request is sent to your insurance company for approval. Once your surgery is approved, it is just a matter of scheduling your surgery date. Please allow three weeks after submitting your papers before you call to check for the status.

69. How soon can I have sex after surgery?
Usually after three (3) weeks.

70. How long does the operation take?
Usually two to three (2-3) hours with the standard open approach. If other procedures are added or a different approach is used, it may take more time. You should discuss this with your surgeon.

71. How much does the surgery cost?
The total cost is about $50,000-$70,000. This includes the hospital fee,the surgeon’s fee, fees for the various consultants and the various tests and x-rays needed. The cash price (up front) is negotiable on an individual basis, and up to a 50% discount can be obtained for prepayment on the complete package.

72. Does Medi-Cal or Medicare pay for this procedure?
Yes, but we have a long waiting list of Medi-Cal patients and Medicare patients.

73. What insurance companies cover the obesity surgery?
Most health insurance, PPO and HMO cover obesity operations, and HMOs are referring patients out for surgery or providing the services themselves. However, there are some health plans that exclude coverage for obesity surgeries.

74. How long does it take to get an approval for surgery from the insurance company?
It varies. Some give an approval over the phone on the first call, but most take four to eight weeks.

75. How much does a panniculectomy cost?
Usually $4,000-$8,000 depending on the size of the pannus.

76. Do insurance health plans cover the panniculectomy?
Rarely. Most patients pay for the panniculectomy.

77. Do insurance companies cover the reconstructive surgery such as breast lift, arm lift, thigh lift, etc.?
It depends on your insurance plan, but rarely is it covered. As a policy, we do not request a payment from the insurance companies for the reconstructive procedures.

78. Can self payments be made for the Operation?
Yes. Payments usually need to be made 2 weeks before surgery date. Only cash, cashier’s check or credit card payments are accepted. Surgeons at the Center are not contracted providers with any insurance company and you can discuss the financial matters with the Financial Consultant at the office. Financing for the operation is also available.

79. What arrangements are available for out of state patients (hotel, flight, etc.)?
Flight and lodging are the responsibility of the patients. There are a few hotels not far from the hospital which are very accommodating to our patients with reasonable rates. Patients can fly into either LAX or Long Beach Airport. Please notify the office of your traveling plans in advance. It is desirable to bring a family member or friend to help you after surgery, but it is not absolutely necessary.

80. If patients come in from out of the area, how long do they need to stay in Los Angeles?
Patients who live more than 150 miles from the hospital should plan to stay in he area for approximately seven days after the operation. Patients with a panniculectomy have to stay an additional week to make sure the wound is healing well before returning home.

81. Who needs to fly in for a consultation and who qualifies for a phone consultation?
Almost all out of state potential patients can have a phone consultation, but some out of state patients may be required to come into the office for a consultation depending on the medical condition of the individual patient. All patients are required to have a primary care doctor who is aware of the plan for surgery and who is willing to provide the follow-up care when the patient returns home.

82. Are there any patients who have been dissatisfied with the FOBI POUCH GASTRIC BYPASS?
Yes, but they are few.

83. What is the mortality rate?
0.5% or one in two hundred (1 out of 200) patients have died within the first thirty (30) days after the operation from various causes. The most common cause of death is pulmonary embolism.

84. Is the surgery reversible?
Yes. It is functionally reversible, but not exactly as nature made it. The stomach and bowel can be connected again to allow eating as before the operation. Of course, another operation is necessary for reversal and you may regain all the weight you lost or more after reversal.

85. Does anybody not lose weight after weight loss surgery?
None of our patients have under gb and experienced no weight lose however, some do not lose enough weight.

86. Has the FOBI POUCH GASTRIC BYPASS been performed laparoscopically?
Yes. 90% of the Fobi Pouch Gastric Bypass surgeries performed at the Center are done laparoscopically.

87. Will Dr. Fobi perform my surgery or will another Surgeon?
You can request Dr. Fobi, but other Surgeons perform the same procedures. These other surgeons are well trained and work independently with excellent results. Call our office for referrals to surgeons that may be closer to you, if you so desire.

88. Do I need a medical alert bracelet?
It is recommended.

89. Who qualifies for the new bikini incision?
Most patients qualify, but some patients may not. You need to discuss this with your surgeon on your consultation visit. The bikini incision is an additional cost.

90. How Long has the Center been perfomimg weight loss operations?
The Center was formally opened in 1981 and Dr. Fobi has been doing obesity surgery since 1977.

91. Are there other Surgeons who perform the FOBI POUCH GASTRIC BYPASS for obesity?
Yes, there are more than two hundred and fifty (250) surgeons who have visited and observed Dr. Fobi perform surgery and have learned how to do the FOBI POUCH GASTRIC BYPASS. There are others who perform similar surgeries, but not exactly as described by Dr. Fobi and are having equally good results. You may call the Center for referral.

92. Does the Center offer general surgery services?
Yes. We perform certain general surgeries concurrently with obesity surgery or after obesity surgery which may include thyroid surgery, breast surgery, tubal ligation and ovarian surgery, hernia repairs and operations on the stomach, small bowel and large bowel surgery, just to name a few.

93. Does the Center offer reconstructive surgeries?
Yes. We offer reconstructive surgeries to our patients, such as breast reduction and mastopexy, arm reduction, hip reduction and panniculectomy (tummy tuck/abdominoplasty).

94. After my weight is stabilized what do I do to avoid weight regain?
Eat correctly, avoid nibbling on chips or candies, take your vitamins, and exercise regularly.

95. What are high proteins?
High proteins can be found in foods like beans, lentils, eggs, chicken, fish, cheese and any meat products.

96. What are carbohydrates?
Carbohydrates are found in foods like rice or rice products, wheat or wheat products, potato or potato products, and any sweets such as bread, pasta, macaroni, spaghetti, french fries, chocolate, cookies, etc.