The most important decision to make after deciding you want to have surgery for your weight problem is, Which operation should Ichoose? This used to be easy and you took what you were offered by your surgeon. Now, with more surgeons offering a variety of surgeries, the situation is vastly different.
While it may be true that all types of obesity operations have a rate of disappointment or failure, either because of technicalcomplications or simply because the surgery didn't work very well, the chances of disappointment are very different for the various operations. Unfortunately, most surgeons don't necessarily know their own failure rate, because they have not done enough operations for long enough, or as sooften happens, the disappointed patients do not return for follow-up.
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The operations currently offered around New Zealand are as follows:
- Laparoscopic gastric bypass (sometimes called Roux-en-Y)
- Open gastric bypass
Often, these procedures are thought to be the same, or to be so similar that it doesn't matter which surgery is selected. Thereality 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 otheropen 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 occurduring 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 O'Brien and others from Melbourne. This shows the percentage of excess weight lost atvarious 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 lossachieved 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 theaverage 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 needfor 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.
· 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:
· 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
Laparoscopic sleeve gastrectomy:
· excellent initial weight loss
· weight regain by 4-5 years common
· short hospital stay
· further revision surgery necessary for 30-50%
· less expensive than gastric bypass
· few if any long-term complications
. problems with acid reflux
Open Fobi pouch gastric bypass:
· greatest initial weight loss
· open surgery
· greatest long-term weight loss
· longer hospital stay and time off work
· most predictable and reliable procedure
· a little more expensive
· revision almost never required
· incisional hernias in 5-10%
· follow up after 2 years seldom required
· need vitamin supplements
This operation developed rapid popularity around the world in the mid 1990s. This was largely because of its seeming simplicity. However in recent years it has become very obvious that it provides unreliableweight loss, and is associated over time with many problems, often leading to band removal or replacement. As a result its worldwide popularity has declined sharply, and it should no longer be considered a satisfactory longterm solution for those with major weight problems. Its popularity inAustralia has however been maintained, probably largely because its cost and that for revision procedures is contributed to by Medicare insurance. This luxury does not exist in New Zealand, where all ongoing costs must be borne by the patient. Very few of New Zealand's experienced bariatricsurgeons now offer this operation and the medium-long results of laparoscopic adjustable banding are now readily available in such publications as long term results of lap banding.
If you are attracted to the Lap Band by its simplicity and cost, it is important to realise that bymaking that choice, you are very likely to require 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.
As we have learned that there is a very high rate of weight regain, reoperation, technical problems and general dissatisfaction with laparoscopic gastric banding more and more surgeons have turned to analternative. Most have chosen to offer laparoscopic sleeve gastrectomy because it is relatively straightforward to do (compared with a gastric bypass), and because its simplicity makes itinherently attractive to both surgeons and prospective patients.
It is known that this operation, which was originally conceived as step 1 of 2 operations for very severely obese individuals, is relatively simple and quick to perform, and achieves about 65-75 % loss ofexcess weight in the first year or two, which is better than can be expected from gastric banding, and similar to what can be expected from gastric bypass. Like all bariatric operations it can be performed with high levels of safety but complications may and do occur. Serious complicationsoccur in up to 5% of individuals, which is very similar to the reported rates of serious complications after gastric bypass.
What has not been so clear is whether this weight loss will be maintained into the medium and longterm. The enthusiastic uptake of this operation by surgeons and patients alike took place with a total absenceof published experience of results beyond 1-2 years. This was similar to the enthusiastic uptake of laparoscopic gastric banding in the mid 1990s. Weight regain has always been the biggest problem and disappointment associated with bariatric surgery. The expectations and suspicions of many surgeons around weight regain following sleeve gastrectomy, is now beginning to be realised. As more and more reports appear in the published literature of 5 year results following this operation, it is clear that a large proportionof patients are regaining weight by 5 years, and many, if they can afford it will need a further operation. As the gastric sleeve distends to allow weight regain, unfortunately the degree of distension and the associated weight regain are progressive. Those who choose this operation must expect that weight regain after 4-5 years is almost inevitable. The level of disappointment that follows will vary depending on need and expectations.
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 seenafter 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 areexcellent - 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 havenever 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!
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