The History of Bariatric Surgery: Forty Years in Bariatric Surgery

by Mathias A.L. (MAL) Fobi, MD, FACS, FICS, FACN, FASMBS

Dr. Mathias A.L. Fobi is a senior staff surgeon at Cedars Sinai Medical Center in Los Angeles, California. He was one of the founding members of the American Society for Bariatric Surgery (ASBS) in 1983. He has served as the President of the American Society of Metabolic and Bariatric Surgery Foundation (ASMBS Foundation), the California Chapter of the ASMBS (CCASMBS), the International Federation for Surgery of Obesity (IFSO), and is the outgoing Chairman of the IFSO Board of Trustees. Dr. Fobi’s modification of the gastric bypass surgery (the banded gastric bypass) is one of his major contributions to the field of bariatric surgery. He has been recognized with many awards including a lifetime achievement award from the ASMBS.

Bariatric Times. 2015;12(8):10–12.

This column is dedicated to telling the stories of leaders who have helped shape the field of bariatric surgery through their discoveries, teaching, and stewardship.

Column Editor: George L. Blackburn, MD, PhD, FACS
S. Daniel Abraham Professor of Nutrition; Associate Director, Division of Nutrition Harvard Medical School; Director, Center for the Study of Nutrition Medicine, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts

Column Editor: Daniel B. Jones, MD, MS, FACS
Professor of Surgery, Harvard Medical School, Vice Chair, Beth Israel Deaconess Medical Center, Boston, Massachusetts

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A Message from the Column Editors

Dear Readers of Bariatric Times:

Bariatric surgery has many leaders who have helped shaped the field by their discoveries, teaching, and stewardship. Bariatric Times has initiated a new regular column titled, “The History of Bariatric Surgery—As Told by the Leaders Who Made it Happen.” We invite leaders to tell us about their most significant accomplishment(s). Here, we will hear from leaders about their visions, hurdles, collaborations, and, ultimately what impact their accomplishments have had on the field of bariatric surgery. We will also learn how they set goals and have turned ideas into reality, as well as what was anticipated and what was not expected throughout their journeys.
We are very excited about this project and hope it will help to inspire the next generation of leaders as they evaluate new devices and technology and consider novel procedures and treatments in an era of cost containment. We hope you enjoy these stories.

Sincerely,
Drs. George L. Blackburn and Daniel B. Jones

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When I was introduced to bariatric surgery in 1975, there was a moratorium on the jejuno-ileal bypass (JIB). Dr. Joseph Alexander, Chairman of the Department of Surgery for King/Drew UCLA Medical Center had just returned from the American College of Surgeons (ACS) meeting where he attended a discussion between Drs. Edward Mason and Howard Payne. He contacted Dr. Mason who sent us a telex (the precursor to the fax and e-mail) on how to convert a complicated JIB to a gastric bypass (GBP). It was a horizontally stapled pouch with a gastro-enterostomy on the greater curvature. Serendipitously, this patient did well and referred other patients for conversion of their JIB to GBP. Severe metabolic complications of the JIB were usually treated with reversal, but many very sick JIB patients did not want a reversal because of the weight regain. Word spread in Los Angeles that there was an alternative operation, and the first 78 cases I did at the King/Drew Medical Center were conversions of JIB to GBP. I performed my first primary GBP in late 1978 after acquiring a Gomez-Poly-Tract retractor (Teleflex Medical/Pilling, Research Triangle Park, North Carolina). I met Dr. Gomez and other notables in bariatric surgery at the yearly Bariatric Colloquium hosted in Iowa City, Iowa, by Dr. Mason.

Center for Surgical Treatment of Obesity
In 1980, I opened the Center for Surgical Treatment of Obesity (CSTO), specializing exclusively in performing surgery for obesity and related reconstructive operations. Initially, there was resistance from prominent surgeons in the community because of the confusion when they heard the phrase gastric bypass for obesity, ignoring the gastric part of it and associating it with the jejuno-ileal bypass. To avoid the misconception, I called the procedure a limiting proximal gastric pouch with a gastro-jejunostomy. (The origin of the eponym “Fobi pouch”).

I also started “The Bariatric Surgery Newsletter,” the only publication at that time dedicated to bariatric surgery, to inform and educate physicians and surgeons about the merits of surgical treatment of obesity. This was the first mini-journal on bariatric surgery until the founding of The Obesity Surgery Journal by Drs. Mervyn Deitel and George S. M. Cowan.

At the CSTO, I had a team of five surgeons with 25 auxiliary staff averaging 40 to 60 bariatric and related reconstructive operations a month. Our patients came mostly from the western states and also nationally and internationally. Over the years, I conducted week-long preceptorships on bariatric surgery free of charge that were attended by bariatric surgeons from the United States and around the world. The surgeons were exposed to the standard procedures and protocols that were followed by all the surgeons at the CSTO, which today is called evidenced-based care delivery. Attendees observed various operations, including primary, revision, and reconstructive; went to weekly, Thursday multidisciplinary conferences with other surgeons, anesthesiologists, a consulting gastroenterologist, radiologist, cardiologist, pulmonologist, psychologist, the hospital’s operating room director, bariatric nursing coordinator, and the rest of the staff at CSTO. These conferences provided a chance for surgeons to review the cases from the past week and the cases for the upcoming week. The visiting surgeons saw patients with the surgeons in the clinic, and attended the introductory informational Friday session and Saturday support group session for patients. Surgeons were taught the need for a multidisciplinary team approach and for ongoing support groups as part of bariatric surgery treatment. They also received copies of CSTO protocols, its database, and informed consent forms that I still see being used at various centers when I travel nationally and internationally. A certificate was awarded at the end of the preceptorship.

Annual Symposium on Bariatric Surgery
In 1981, I held a symposium at the King/Drew Center where I was the Chief of the Division of General Surgery. Dr. Mason was the main speaker. This symposium evolved into a yearly international meeting until 1992 when I made the decision to end the symposium to avoid competition with the American Society of Bariatric Surgery (ASBS) annual meeting. The ASBS (now the American Society for Metabolic and Bariatric Surgery [ASMBS]) was officially formed in 1983, and I served as a member at large on its Executive Council. Financial support for the Annual Symposium came from Dominguez Hospital, which was the first in the National Medical Enterprises (NME) chain of hospitals that ultimately became Tenet Healthcare. NME sponsored a group of guest faculty for those meetings—all notable professionals in the field of bariatric surgery. It was at this Annual Symposium in 1984, that gastroenterologist Dr. Lloyd Garren introduced a gastric balloon, which was later approved by the United States Food and Drug Administration (FDA) as the Garren-Edwards Gastric Bubble (American Edwards Laboratories, Santa Ana, California). It was also at this meeting that Dr. Lubomyr Kuzmak introduced the concept of adjustability to the gastric band for conventional open surgery.
The annual symposium became the bariatric meeting to attend. In 1987, Dr. Cowan hosted it at the Peabody Hotel in Memphis, Tennesee. This symposium provided an open forum to debate the merits of the various operations. I remember most outstandingly the exchange between Drs. Nicola Scopinaro and Marcel Molina. One was advocating a very effective but complicated operation (biliopancreatic diversion [BPD]) with many potential adverse events, and the other was a proponent of a relatively safe and easy procedure, gastric banding (GB), which, in my opinion, was not very effective. I believe there is still need for an effective operation that is also safe and relatively easy to perform. This annual symposium, with the media coverage and its international participants, including the following: Eoghan R. T. C. Owen, United Kingdom; Scopinaro, Italy, Folke Ericksson, Switzerland; Knut Kolle, Norway; Andrew Jamieson, Australia; Rafael Alvarez, Mexico; Alberto Salinas, Venezuela; Luc Lemmens, Belgium; Ilan Charuzi, Israel; Peter Salmon and Mervyn Deitel, Canada; Isoa Kawamura, Japan; and Richard Stubs, New Zealand, popularized bariatric surgery in the United States and worldwide. The friendship and comradery from this meeting resulted in subsequent meetings in Israel, Australia, Japan, United Kingdom, Italy, and Sweden where The International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) was formally founded in 1995.

Banded gastric Bypass (the Fobi Pouch Operation)
I was introduced to the vertical banded gastroplasty (VBG) in 1981 when Dr. Mason visited the King/Drew Center. I did one of the first prospective evaluations comparing the VBG to the GBP. I later changed to doing the silastic ring gastroplasty (SRVG) in 1984 because it appeared to be a less invasive operation. By 1985, I started seeing patients return with weight regain, particularly after the VBG/SRVG operations, but also after the GBP operations. The VBG/SRVG patients were failing after two and three years and the failure in the GBP was becoming evident in the fourth and fifth year of follow up. A failed VBG/SRVG was converted to GBP and a failed GBP either had a revision of the pouch and the gastrojejunostomy or was modified to a distal gastric bypass (DRYGBP) by shortening the common limb. Adding malabsorption to the GBP was based on the excellent weight loss outcome that was reported from the biliopancreatic bypass now called biliopancreatic diversion (BPD).

I was a member of the National Bariatric registry that Dr. Mason started, which eventually became the International Bariatric Registry. All data from the operations we performed at the CSTO were entered into this registry. The prospective data on the revision operations were reviewed for a presentation at the ASBS annual meeting in Toronto, Canada in 1989. It was then that I discovered that VBG/SRVG converted to GBP leaving the ring/band in place and making the gastrojejunostomy distal to the ring/band resulted in better weight loss and weight loss maintenance than either the VBG or standard GBP. Coincidentally, Dr. Ilan Charuzi gave a presentation at that same meeting and arrived at the same conclusion. This gave birth to the banded gastric bypass (BGBP) or the Fobi Pouch Operation for Obesity (FPO). The BGBP has evolved with a better understanding of the mechanism of its effectiveness. Banding the pouch in a failed GBP and in patients with reactive hypoglycemia after GBP are now standard revision operations. Most of the BGBP were done with surgeon-fashioned devices, such as Marlex mesh, fascia lata, silastic rings, and various tubings. Now, there are prefabricated devices for banding the gastric bypass.

Other Contributions
When the ASBS was formed, most of the innovations in bariatric surgery were coming from surgeons in private practice. I, as a member at-large on the first ASBS/ASMBS Executive Council, with the support of many others insisted and made sure the constitution of the ASBS/ASMBS provided that the Presidency of the Society alternated between a surgeon in private practice and a university-based surgeon (Town and Gown). Since then, that tradition has been maintained. In the beginning there was some tension between university-based surgeons and surgeons in private practice on many issues, such as: 1) Was there a justified need for an independent society separate from general surgery? 2) Was there enough material to support an independent journal? 3) the quality of the presentations at the meeting, 4) untested innovations in bariatric surgery, 5) the use of support groups, 6) advertisements, and 7) the need for an ASBS foundation. With time, we now have a happy medium.

Final Thoughts
As I look back over the 40 years that I have been involved in bariatric surgery, I am content with my contributions to the promotion and acceptance of bariatric surgery as mainstream surgery. I believe this was made possible by the location of my practice in Los Angeles, California, where I treated many celebrities with the associated media coverage.

Funding: No funding was provided.

Financial Disclosures: The author reports no conflicts of interest relevant to the content of this article.

Author affiliation: Dr. Fobi is Senior Staff Surgeon at Cedars Sinai Medical Center in Los Angeles, California.

 

Tags: banded gastric bypass, fobi pouch

Category: History of Bariatric Surgery, Past Articles