The Limiting Proximal Gastric Pouch, called “Fobi-Pouch 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 operation, “The Fobi-Pouch for Obesity” has an operative mortality of <.02% and significant morbidity of <10%. It is 95% effective with greater than 50% excess weight loss that is maintained for more than five years of follow up. Long term related complications are limited to Fat soluble vitamin deficiencies, Calcium, Iron, B12, and Folic Acid deficiencies with the resultant anemia. All of these can either be prevented or corrected. There are occasional problems with frequent vomiting, diarrhea and meat intolerance. The operation is completely reversible if the need does arise. The Fobi Limiting Proximal Gastric Pouch 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 distal stomach perioperatively. The gastrostomy site has a silastic ring marker to facilitate percutaneous radiological evaluation of the distal stomach if the need arises. The Fobi Pouch has the following significant characteristics:
- Vertical <30 cc pouch Easy to intubate, less distensible, provides early satiety.
- Transected Pouch
Minimal mobilization, no problem with staple line breakdown, minimal occurrence
of marginal ulcers.
- Banded pouch, longer band, 5.5 – 6.5 cm
Leaves a large stoma – but limited in diameter, allows dumping — but not severe
dumping, band has not be documented to erode in a primary case.
- Imbricated Gastrojejunostomy
The limb of the jejumun 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.
- Large gastroenterostomy 1.5 – 2 cm long
Markedly decreased rate of gastric outlet stenosis
- 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.
- Marked gastrostomy site
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 complications from this operation are Vitamin A, D and E, Calcium, Iron, B12 and Folic Acid deficiencies and the associated anemia. 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:
- Acute gastric distention with or without perforation.
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 NPO for 7 days to two week has 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 an intraoperative traumatic complications.
- 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. There are, to date, no controlled studies to show that there is a significant difference, if any, in the restrictive operations when the pouch has been maintained at a size less than 50 cc. It should be noted that as much as the idea of measuring the pouch is stressed by many, there appears to be no difference between an estimated pouch and one that is measured on review of various series in the published reports.
- 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 bowel obstruction, particularly 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 anatomizes;
c) closing the gap between the Roux-Y Limb 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 purposed in cases of rapid weight loss, problems with the gastric outline, 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 is 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. Fat Soluble Vitamins B12, Iron, Calcium and the associated conditions.)
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.)
Information of these deficiencies are 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 includes CBC, SMA 22, thyroid profile, HIV test, 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 treatment of patients, consisting of an anesthesiologist, scrub nurse, circulating nurse, patient counselor, cardiologist, pulmonary specialist and two surgeons.
Other consultants are called preoperatively 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 assess the risk benefit ratio.
All patients have stomach X-rays within two weeks after the operation. Yearly stomach X-rays are planned for the first three years, and as necessary thereafter. Radiographic evaluation of the distal bypassed stomach is recommended every five years after age 50.
- Safe <10% perioperative morbidity<1% mortality
- Effective >50% excess weight loss in 95% of patients 5 years
- Reproducible Surgical technique should be easily reproducible. Results from various centers should be comparable.
- Minimal Revision Rate <2% per year.
The Fobi Pouch Operation meets all the above criteria and more.