Sunday, June 20, 1999
Copyright © Las Vegas Review-Journal
Quoted from this News Article: “Dr.
Barry Fisher, a
professor at the University of Nevada School of Medicine who is the only doctor
performing bariatric surgery in Las Vegas.”
THROUGH
THICK, THIN
Couple loses 500 pounds
after having controversial surgery.
By Caren Benjamin
Review-Journal
Carolyn Travis begins the
meeting by passing around her 1993 wedding album and complaining gently about
her outfit in the photos.
"They don't make gowns for 300-pound brides," she beams, a platinum blonde
who now weighs half that.
Her husband, Gary, announces he was 540 pounds. He has lost about 320
pounds. The discussion goes around the table.
"My name is Jason and I lost 190 pounds."
"My name is Tim. I lost 135 pounds."
Many have before pictures like the Travises' wedding album that they
display to each other in triumph.
They give testimonials to little miracles.
"I walked up the stairs," says one woman.
"I love having a lap," says another.
One man has brought his son along. The boy, about 8 years old, tells the
woman next to him his daddy used to not be able to "walk down the Strip."
"All he did was watch videos."
"Now he can do stuff," the child says.
Those testifying have undergone massive surgery that has reshaped the way
their bodies do business. What was once their stomach is now their "Fobi pouch,"
named for Dr. Mal Fobi whose Bellflower, Calif., Center for Surgical Treatment
of Obesity was the site of their transformation. There are about 40 people at
the February support group meeting in Las Vegas of people with Fobi pouches.
Higher powers
Dr. Hoil Lee, a California surgeon who works with Fobi, says hundreds of
patients have gone there from Nevada to receive the surgery. There is a Southern
Nevada surgeon offering obesity surgery, but he has much stricter limits about
who he will operate on than Fobi.
The group is part bonding session, part information sharing. Most people
there have had the surgery. They talk about how they eat, what they feel and how
they've changed and encourage one woman considering the surgery.
It's a little like watching a gathering of Alcoholics Anonymous. Like AA
members the formerly fat of the Fobi group have given their problem over to a
"higher power" -- in their case a doctor -- who they believe has proven himself
worthy of their faith.
Unlike AA members who are recovering, they have, for the most part
recovered. They are thin, or at least thinner than they were, able to go to the
movies without looking for a handicapped seat, able to go to a restaurant and
not worry if it has armless chairs.
What a potential surgical patient doesn't see at the meeting is those who
have fallen off the wagon -- the people whose bodies didn't take well to
surgical manipulation. These are people who think they have been victims of a
hard sell in a lucrative industry.
Take Lisa Ross. She nearly starved to death. She says she is sick all the
time. A few months ago a Long Beach, Calif., jury awarded her $2.6 million in a
medical malpractice case against Fobi.
Or Patricia Wendland. She and her best friend, Bonnie Robertson, both got
the surgery. Bonnie Robertson is dead.
Mortality rates
Bariatric surgery has a much higher mortality rate than other kinds of
surgeries, according to Dr.
Barry
Fisher,
a professor at the University of Nevada School of Medicine who is the only
doctor performing bariatric surgery in Las Vegas.
Fisher
estimates between 0.2 percent and 0.5 percent of patients who undergo obesity
surgeries die as a result of complications from the procedure. That's compared
to about a 0.001 percent fatality rate for patients who have surgeries like
gallbladder removals and appendectomies,
Fisher
said.
He has lost one patient of more than 200 he has operated on. "It was
devastating," he said.
Fobi's brochures listed a zero percent to 1 percent chance of death as a
post-operative complication.
Dangerous yes,
Fisher
said. But he notes that about 300,000 people in the United States a year die
from complications or "co-morbidities" related to obesity including hypertension
and diabetes.
More dangerous, in his opinion, is the fact insurance companies are often
reluctant, or flat out refuse, to cover bariatric surgeries because there is a
pervasive belief the procedure is somehow cosmetic surgery.
"No one is fat because they want to be," he said. New research shows in
most cases these are people who have a genetic tendency toward obesity.
On this he and Fobi's group of surgeons agree.
Where they differ is on the types of surgery they offer. While the process
is quite similar, the involvement of the patient differs vastly as does the
surgeons' criteria for surgical candidates.
Fisher
believes the patient is an active participant, the surgery simply a tool for
weight loss.
Fobi's patients believe -- some of them rightly -- that they are cured of
being fat.
The danger, Fobi's detractors say, is his patients don't always have all
the information they need before going into the surgery about how their
individual bodies will react, nor do they have the medical support they need if
something goes wrong.
Surgical categories
The most common forms of bariatric surgery fall into two broad categories.
Gastric bypass is an operation that reroutes the small intestine, thus keeping
most food out of the stomach. Gastroplasty is the surgery commonly known as
"stomach stapling" though surgical staples are used in both procedures. The
second procedure limits the size of the stomach and therefore the amount of food
it can hold.
Versions of these operations have been performed since the 1970s with
varying degrees of success.
The problem with a straight gastroplasty is that stomachs stretch and so
the effect of restricting food intake can disappear over time, according to Lee.
The operation that creates the Fobi pouch is a combination of the two
types of surgery with an added element, Lee explained.
The stomach is divided to create a pouch that holds about a sixth of a cup
of food. The rest of the stomach is stapled shut. The small intestine is
surgically divided and one section of the cut intestine is connected to the
stomach pouch. A plastic band is then placed in the middle of the pouch to
create a valvelike opening.
The band causes solid foods to stay in the stomach for a while to create
the sensation of being full, Lee explained.
Fisher
does gastric bypass operations. In his operation, food never hits the larger
part of the stomach. While
Fisher
says, "no one is exactly sure what the best way to do this is," he also claims
the gastric bypass is the procedure that has had the most scientific scrutiny
and he believes it both the safest and most effective.
Surgical safety
Safety of surgical procedures is virtually unregulated, according to Dr.
Ed Livingston a surgeon at the University of California, Los Angeles.
"I could invent an operation called the Livingston procedure and there's
absolutely nothing anyone can do about it."
The most scrutiny a new surgery procedure receives is a peer review
process in which doctors look at each other's work. The problems with this are
myriad, Livingston said, beginning with the fact "at Fobi's hospital those who
peer review Fobi are his partners."
Livingston operated on Lisa Ross and, she says, saved her life. The Orange
County, Calif., woman got a Fobi pouch in April 1996. By the end of August she
had lost far too much weight too fast and said "I was so sick I couldn't sit
up."
In January 1997 she went to UCLA suffering from severe malnutrition.
The problem, Livingston said, was the area around the band became
infected. Livingston said he has seen her problem before on Fobi patients.
"I've also seen lots of complications from the operation that are really
kind of unexplained. People are dying," said Livingston, who is also chief of
surgery for the Veterans Affairs health network in Los Angeles.
Las Vegan Bonnie Robertson was one of those people, according to a lawsuit
filed by her friend Patricia Wendland in District Court in December 1996.
Robertson, 52, died of malnutrition in February 1995, less than two years after
her Fobi pouch operation.
She was 85 pounds at death, according to the lawsuit. The case of Wendland
vs. Fobi is pending in District Court.
Fobi is not granting interviews, according to his publicist.
Lee admits there can be complications. The fact it is a major surgery that
can lead to death is clearly stated in brochures explaining the procedure to
potential patients.
The problem with the band he says happens to maybe one in 100 patients.
Usually "we wait about six months to see how the person is doing and if the
problem still goes on we take the band out."
Ross says she was told the surgery was completely reversible. Lee says
that it is.
Livingston scoffs at that.
"You may be able to reverse the surgery but things will not work the same
way afterwards," he said.
Lee also freely admits the original surgery is often not the only one many
patients will need.
Gallstones are a common after-effect of rapid weight loss and may require
removal of the gallbladder, he said. Many patients also will need cosmetic or
reconstructive surgery to tuck flaps of skin hanging off shrunken stomachs,
breasts, arms and thighs,
Fisher
told potential patients at a seminar explaining the procedure.
Patients at the Fobi support group spoke of these additional surgeries as
if they were no big deal.
"I would do it again," all said of the original surgery as they went
around the table talking about the weight they lost. "I would do it again a
hundred times," said one woman who announced she "would rather be dead than
fat."
Different approaches
Fobi and
Fisher take vastly different
approaches to how they select patients and how those patients are told to
participate in the process of their own weight loss.
To determine who is a candidate for surgery
Fisher
looks first at Body Mass Index, a system designed to compare the relatively
obesity of people of different heights. The National Institutes of Health says a
person with a BMI of more than 40 -- about 100 pounds overweight for men and
about 80 pounds overweight for women -- indicates a person is severely obese.
Other physical factors to take into account are a person's body-fat to
muscle ratio and whether the person has co-morbidities related to obesity,
Fisher
said.
He will not, under any circumstances, operate on someone who smokes
because wounds don't heal as well in smokers.
Fisher
says he looks for people who really want to change their lives. He considers
that as important as any physical factors.
He takes an extensive diet history of a potential patient and won't
operate on anyone who has not tried every other method of weight loss and had
some short-term success that indicates some level of self-control and interest
in change.
This is important because the operation only works as long as patients are
trying to help themselves, he said.
"You can gain weight after this surgery if you eat constantly," he
explained.
His patients also must undergo counseling before the surgery with a
licensed clinical social worker.
On the day of discharge from the hospital his patients are given the "Nine
Rules" of eating.
The stomach after surgery can hold 4 ounces. He suggests 2-ounce meals. He
stresses no junk, no sweets, no "noshing." The rules include a mandate to "eat
three meals a day." He recommends people take five weeks off work after the
surgery to rethink their relationship with food.
His rules are inflexible. He told one potential patient to diet and take
off 100 pounds before surgery. The man was losing weight and complying with the
diet but his mother was the one keeping the diet log and calling the doctor
regularly. Fisher
canceled the surgery because he decided the patient himself wasn't committed. He
has had business people who "don't have time" to diet who think the surgery is a
quick fix. He has refused to operate on them.
Ethical questions
Carolyn Travis questions whether this approach is ethical, given what
potential patients are facing in their lives if they don't have the surgery. She
said she never would have considered something as serious as surgery if she
hadn't "been on every diet in the world."
The emotional pain associated with obesity also should count for something
she suggests. Most people who would consider drastic surgery have hit bottom in
their lives.
For her she says it was when she finally gave up dancing, her favorite
activity, because she couldn't stand people staring at her. Her husband Gary
said it was when he started to get belligerent. He remembers telling a little
girl in the supermarket that it was rude to point and stare. The child's father
told him "if you don't want to be looked at you shouldn't go out," Travis
remembers. "I almost hit the guy, I would get that way a lot if people stared at
me, I'd be in their face."
"How can you turn down a 500-pound person who doesn't meet your standards?
This is their last hope. Now they're crushed," Carolyn Travis asked.
Fobi's group of surgeons, on the other hand, will operate on anyone who is
100 pounds over ideal weight or 75 pounds overweight with other co-morbidities,
Lee said.
As for psychological suitability for surgery, "before they come here I
would say 99.9 percent of patients have gone through a lot of diets and things
so I don't need to ask them," Lee said, adding that insurance companies often do
the asking before agreeing to pay for the procedure.
For post-operative eating, he suggests eating what feels right -- within
reason. Both
Fisher and Fobi's operations
can cause dumping an unpleasant sensation of nausea and cramps after eating
sweets. Brochures for the Fobi pouch suggest staying away from fatty foods,
empty calories and carbonated drinks.
Wendland suggests a doctor has some obligation not to operate on anyone
who wants it -- despite their weight.
"I had no health problems from being overweight. People like me should
have been told to get on a diet, do exercise. I shouldn't have had surgery,"
Wendland said.
Success or failure?
Success rates are difficult to track,
Fisher
says. He has one patient who lost 200 pounds.
Fisher
considers him a success. The patient wanted to lose 300 pounds. He thinks he's a
failure, the doctor said.
Of 24 patients
Fisher
operated on in 1990, 18 of them were within 25 pounds of their ideal weight six
years after their surgery. Of the nearly 200 patients he has operated on since
1995 he guesses 75 percent have lost and kept off 50 percent of their excess
weight.
While his protocol is narrow for who he'll operate on,
Fisher
is clearly enthusiastic about his product. He tells the nearly 40 people who
have attended an informational meeting on a recent evening, most of whom are
varying degrees of overweight, that they could die of blood clots as a result of
the surgery. He tells them this is going to be the hardest thing they have ever
gone through, even if they are successful.
But he also shows before and after pictures. He preaches to choir members
who already know they are suffering discrimination, sometimes subtle --
sometimes outright. He tells them about the newly thin and their newly
blossoming careers. He shows a picture of a former client who lived with her
parents and described her life as a cycle of work, food and television. Then he
tells about how he saw her a few years later, thin, married, a mother.
Lee says the chances of gaining weight after a Fobi pouch operation is
less than 10 percent.
That's about all Ross said she heard when he went to Fobi's office seeking
information.
"Boy were they attentive. They were on you, asking questions, telling you
exercise doesn't work, diets don't work. They say `I bet you've been on diets,
I've bet you've gained it back, twice as much.' And of course it's all true."
It was after, when she was having problems that she was told her body was
under her control. "They said it was my fault, I wasn't eating right, I wasn't
chewing properly," Ross said.
Wendland, too, says she wishes she had more information before getting the
surgery and then more support for her friend when things started to go wrong.
When her best friend got sick, then sicker, she said she started going to
the meetings trying to tell potential new patients that "this isn't for
everybody, this is experimental." She says she was practically drummed out of
the group. In fact, she said someone, possibly one of the doctors, started a
rumor that Robertson committed suicide.
"He said she wouldn't eat. It made me cry. I saw how hard she struggled to
live."
Members of the Fobi support group have had very, very different
experiences with Fobi and with the aftermaths of their operation.
"He diagnosed what was wrong with me over the phone," said one successful
patient. "Dr. Fobi is always there for me, he is just the kindest man," says
another.
The group is joined on that day by Dave, who Fobi operated on for free.
Dave got the operation after appearing on Roseanne Barr's talk show discussing
how he was near suicide at one point. Roseanne, a successful recipient of the
Fobi pouch, invited him and Fobi to the show.
Dave has promised to lobby whomever he can find to make sure that anyone
who needs this surgery can get it. The hope it gave him, he is sure, saved his
life.
"It's like freedom from bondage," he said. "I'm free of the bondage of
food."
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