Which Operation Should I Choose?

The most important decision to make after deciding you want to have surgery for your weight problem is, Which operation should I choose? This used to be easy & you took what you were offered by your surgeon. Now, with more surgeons offering a variety of surgeries, and even more expected to be developed, the situation is vastly different.

While it may be true that all types of obesity operations have a disappointment or failure rate, either because of technical complications or simply because the surgery didnt work very well, the chances of disappointment are very different for the various operations. Unfortunately, most surgeons dont necessarily know their own failure rate, because they have not done enough operations for long enough, or as so often happens, the disappointed patients do not return for follow-up.

We are one of the few groups in the World to have published our medium-long term results (up to 14 years) and for that reason can offer the Fobi Pouch Gastric Bypass with confidence. Click here to see those results.

The operations currently offered around New Zealand are as follows:

- Laparoscopic banding

- Laparoscopic gastric bypass (sometimes called Roux-en-Y)

- Open gastric bypass

- Laparoscopic sleeve gastrectomy

- Open Fobi Pouch gastric bypass

Often, these procedures are thought to be the same, or to be so similar that it doesnt matter which surgery is selected. The reality is that these are all vastly different operations. In particular, the gastric bypass, sometimes referred to as the Roux-en-Y procedure is very different from laparoscopic banding, and the Fobi Pouch gastric bypass is very different from other open and laparoscopic gastric bypasses.

The choice of operation should take a number of things into consideration:

1. length of hospital stay and time off work

2. size of scars

3. cost and safety

4. amount and reliability of initial weight loss

5. reliability of long-term weight loss

6. proportion of revision operations needed

7. proportion of reversals needed

8. need for long-term follow-up

9. possibility of technical problems in the future

Unfortunately, the differences between the operations often take some years to become apparent.  By this time revision surgery, or reversal if revision is not possible, become the only answer. This is often a source of major disappointment.

The truth is that all operations are very safe in experienced hands. However, occasionally unexpected and serious problems can occur during any operation. The following figure is reproduced from a systematic review of the worlds published literature - published in the International Journal, Obesity Surgery in 2006 by Professor Paul OBrien and others from Melbourne.  This shows the percentage of excess weight lost at various time points following surgery. This is an average of all those having surgery in many centres. 

Gastric bypass (which is a mix of laparoscopic and open procedures) shows much better weight loss in the early stages than Lap Band, and continues to show improvements into the long-term. The Open Fobi Pouch gastric bypass surgery shows even more superior results than both of these techniques.

For someone with a start weight of 130kg and an ideal body weight of 65kg (168cm) the 15%-20% improved excess weight loss achieved by the Fobi Pouch operation might translate into a weight of 80kg after 3 years - rather than 90-95kg!

A key factor to consider however, which is not shown on the figure, is the variability of results. The variation above or below the average is quite small for Fobi Pouch surgery, a little more for gastric bypass and much more for Lap Band. This is reflected in the proportion of patients being dissatisfied with their weight loss some years later and the need for revision surgery for each of these procedures. Whereas the need for revision or repeat surgery after Lap Band is common, that after laparoscopic gastric bypass is unusual, and after Fobi Pouch gastric bypass revision is almost never required.

Laparoscopic banding:
Strengths	Weaknesses
·        simpler surgery (patient and surgeon)	·        smaller, less reliable weight loss
·        short hospital stay and time off work	·        life-long band maintenance required
·        cheaper initial cost	·        high ongoing revision rate (5-10% pa)
·        readily reversible	·        high reversal rate (20-40% after 5 years)
	·        ongoing need for voluntary dietary restraint
Laparoscopic gastric bypass:
Strengths	Weaknesses
·        simpler surgery (for the patient)	·        intermediate initial cost
·        short hospital stay and time off work	·        generally some weight regain with time
·        more reliable weight loss than lap band	·        not easily modifiable if revision needed
·        follow-up after 2 years seldom required	·        need vitamin supplements incl. B12 injections
Open Fobi pouch gastric bypass:
Strengths	Weaknesses
·        greatest initial weight loss	·        major open surgery
·        greatest long-term weight loss	·        longer hospital stay and time off work
·        most predictable and reliable procedure	·        most expensive
·        revision almost never required	·        incisional hernias in up to 10%
·        follow up after 2 years seldom required	·        need vitamin supplements incl. B12 injections

Lap Band surgery is the predominant form of surgery offered in Australia, and is becoming more widely offered in New Zealand. However, every year around 15-20% of the operations performed in Australia are revision procedures, and around 25% of weight-loss operations are being reversed. In addition, around 10-15% of patients who have the lap band surgery will experience a very disappointing weight loss. Unfortunately there is too little information available and too little discussion undertaken regarding the medium-long results of laparoscopic adjustable banding, but such information is available in such publications as long term results of lap banding.

As more and more surgeons come to realise that lap band surgery can be disappointing for so many, a few years down the track, they are turning to another relatively simple procedure the laparoscopic sleeve gastrectomy. Although experience with this operation is relatively young throughout the world, it is gaining a growing following because of its simplicity. But for those surgeons who have been doing this procedure for many years (in Europe), it is well recognised that as many as 40-60% of those who have had this surgery, require further surgery within 5 years because of either disappointing weight loss or weight regain. In the New Zealand environment the personal cost of further surgery may prevent it being undertaken. Once again, this highlights the importance of making the right decision about which operation is for you.

The strengths and weaknesses of the commonly performed procedures in New Zealand are shown in the following article, which we wrote for the New Zealand Medical Journal, but which was turned down for publication. It seems the messages contained in the article were thought to so obviously favour the Fobi Pouch operation, that it was not considered balanced by at least one reviewer! I wonder what operation he was offering!

If you are attracted to the Lap Band by its simplicity and cost, it is important to realise that by making that choice, you may well face the need for revision or reversal in the future and there can be some quite serious implications related to band slippage that can occur at any time, which require urgent further intervention or surgery.

  The Fobi Pouch operation was developed in the early 1990s by Dr Fobi, a surgeon in Los Angeles, and has evolved to minimise the occurrence of failure and/or disappointment that was seen after other forms of gastric bypass.  We began offering this form of gastric bypass in 1997 (having been doing a very similar operation since 1990) and have performed it exclusively since 1999. Our long term results (shown over 14 years) were published internationally in 2005 and are excellent - as shown in the figure. We have yet to see a patient who has not lost a considerable amount of weight, and have found our predictions of achievable weight loss to be generally very accurate. With the exception of having to remove the ring (now in about 2% of patients), we have never had to revise or reverse a Fobi Pouch operation. For this reason, we believe that the extra cost - and the more involved surgical process - is well worth considering, in order to achieve the superior weight-loss and more durable benefits of the Fobi Pouch technique.

  The choice is yours. Choose wisely!