March 9, 2009 -- For Carol Poe, obesity is the most painful problem in the world. She tried everything from dieting to bariatric surgery to reduce her body weight. As these methods continued to fail, Poe, tired of being morbidly overweight, underwent the most radical treatment ever devised for obesity -- brain surgery.
Poe is the second person in the United States to undergo deep brain stimulation for weight loss. In deep brain stimulation, electricity is introduced to specific parts of the brain that are believed to control specific behaviors, in Poe's case, feelings of hunger and satisfaction.
"So what they're going to do is ... insert needles into the part of my brain that controls the food," Poe, 60, said before the surgery. "And then they'll put wires underneath my scalp, and it'll go down on each side of my clavicle, [where] I'll have a battery pack."
Now 5 feet 2 inches and 230 pounds, Poe, a married mother of two, said that at her heaviest she weighed about 490 pounds.
"When you're heavy and you walk down the street … everybody looks at you and they're snickering and they're laughing," she said at her home in Morgantown, W. Va. "When you go on an airplane and everybody looks to see if you're going to be able to sit in a seat … the weight has just taken over my life."
During the surgery, the team of doctors would target Poe's brain as opposed to her stomach.
"I've just known in my heart that there had to be something else. That there had to be something," she said before the procedure. "I've tried everything else. I've tried all the fad diets. I've tried liquid protein. I've tried Redux, Fen-Phen. I've had a stomach bypass. I've tried the Atkins diet. I've tried them all. And it's not coming off. So I really believe that it's got something to do with the brain."
Deep brain stimulation has already proved successful in the treatment of neurological conditions such as Parkinson's disease and epilepsy -- eliminating or reducing the tremors and ticks. Surgeons believe the procedure is effective in treating behavioral problems, such as obsessive compulsive disorder and depression, and now hold hopes about using it to fight obesity.
Neurosurgeons from West Virginia University Hospital are leading the way with a Food and Drug Administration approved study of deep brain stimulation for the treatment of obesity.
"This is not for overweight patients. It's for obese patients," said Dr. Julian Bailes, chairman of West Virginia University's department of neurosurgery, acknowledging that currently two-thirds of the American population is overweight. "Remember that obesity itself will reduce your life expectancy maybe 20 years. It's associated with many other diseases: diabetes, heart disease and others. So it's a real problem. ... We think our responsibility as physicians who maybe have a better understanding than most is to look at the potential and sort of the intervention of the brain."
Only patients who've tried every other treatment, including bariatric surgery, qualify for the study. And all must undergo a detailed psychiatric evaluation.
"She has a good profile," Bailes said of Poe. "She's failed the best surgery that we know of, which is gastric surgery. ... So I think it is the best chance for them, for her."
Skeptics may wonder if deep brain stimulation is a drastic medical treatment for a behavioral problem, but Bailes believes "there is a medical issue of obesity."
"I believe that many people have done everything they can," he said. "And maybe there's some predisposition. Maybe there's some effect that the brain cannot control exactly what we consume."
There are risks associated with the surgery -- from infection and hemorrhaging, and in the most extreme cases (less than 1 percent) paralysis or death. Bailes said the FDA had been "appropriately scrutinizing" the study.
"For some, it may seem radical that elecrodes should be put in the brain, that someone should be doing brain surgery for obesity. But I think we've gotten through that and we are very happy to be able to do the first series of patients here, looking at the effects and possible benefits.
"This is a frontier of medicine, a frontier of neurosurgery, a frontier of neurological disease, to be able to generate tiny pulses of electricity in these deep nuclei of the brain, and to see what effect they may have on behavior, including in this case the behavior of eating and the issue of uncontrolled appetite."
Since there are no pain receptors in the skull or brain, Poe required only a topical anesthetic wash applied to her scalp. She was awake throughout the surgery.
"I'm excited about being awake. I want to be awake," she said. "Because if I'm awake, I'll know everything that's going on."
The neurosurgeons, Drs. Michael Oh and Donald Whiting, drilled about 10 centimeters into Poe's brain, on both hemispheres, through a pathway of tissue that does not affect other functions. When they reached a point in the hypothalamus, which controls the stomach, a wire was introduced that would ultimately carry an electrical impulse. The plan was to alter the level of electricity that's generated by that region naturally, thereby giving Poe the sensation of feeling full.
Oh followed the surgery on a computer, which helped the surgeons find the point at which they'd introduce electrodes.
"Although we are applying this technology for obesity, there are certainly many more possibilities in the near future that are going to be available for people with many neurodegenitive disorders," Oh said.
Controlling the Body With the Brain
To some extent, the surgeons are able to evaluate patients' reactions during an awake surgery and talk to them.
"During this procedure, when we have the electrode in this target, we will be asking her about stimulation-induced responses, whether she has a feeling of hunger whether she has any memory responses," Oh explained.
During the surgery, the surgeons can actually provoke a reaction to this electrical current and control the current by adjusting the amount of electricity applied.
Once they get a successful response, doctors "implant a permanent generator, and they have this constant electrical current to that part of the brain," Oh said.
Poe said the procedure didn't hurt but found the stabilization device the doctors put on her head uncomfortable. "It's just real tight," she said. "Like your head is in a vice."
After about an hour of the most delicate movements, doctors believed they'd reached the precise spot. When the electrical current was first introduced, doctors asked Poe if she felt hungry or full, and also whether she felt hot or cold.
"I'm getting warm now," she said. "Yeah, I was cold." The tested electricity was lowered. Poe was unaware of when the doctors signaled for a change in the electrical current, so she couldn't play into what she believed they might want to hear.
"Tell me if that changes anything," said Whiting.
"Yeah, I'm cooled off," said Poe. "I really am. Yeah, I am pretty cool."
The so-called thermostat of the brain, where we get our sense of temperature, is right next to the region where the stomach is also controlled.
Poe said she felt fine, and even at a moment like that, her favorite beverage came to mind. "I sure could use a Pepsi, though," she said. "I told him to find the Pepsi button. He must have found it. Woo!"
Almost miraculously, doctors were controlling Poe's stomach through her brain.
"And then they started to turn it up, and I had to tell them if I felt anything different. Like I started getting real hot. And then I felt like I was going to throw up," Poe said later.
"They knew exactly every pinpoint," she said. "It was like they knew my body. They knew how my body was reacting to everything, and they knew what to do to make it back where it should be."
The surgery lasted three hours. Poe remained in the hospital, and two pacemaker-type devices were implanted into her chest to control the amount of voltage that is sent to her brain.
"You want to do a touchdown end-zone dance, because it was exactly what we wanted to get with the location and the voltage,"said Whiting immediately after the surgery.
Whiting also discussed why maintaining a constant dialogue with Poe was so important. For more than 40 minutes, doctors kept talking, asking Poe repeatedly how she was feeling.
"She wants to … theoretically give us the answers we want to hear and what we want to is without her knowing [is] change parameters to see if it was consistent," Whiting explained. "And in fact there were some things early on that weren't consistent, and we knew they weren't for real, but the nausea findings were very consistent so we very well [could] prove that they were for real."
Creating 'a Sensation of Fullness'
In the months ahead, the voltage going into Poe's brain will be turned on and then increased over time. "She got a nausea feeling at higher voltages," said Whiting. "Our ideal plan would be to set the electrical setting at just below that threshold of nausea where she doesn't really feel any different but still readjust her weight thermostat so that she can metabolize better and actually eat less if that's what it takes."
The morning after surgery, Carol was irrepressible.
"I didn't think I'd feel this good today," she said. "I really feel good. I could go home if they'd let me, because I'm that confident about it. I don't worry about going home and something happening.
"I think the best part of the surgery was the fact that I was awake.
"And I got to hear everything that was going on. I could hear the drill drilling into my head, and I thought, 'Oh my God.' And it was like a big bunch of pressure, like when you push down on something. I could feel all the pressure. And then I could actually feel the drill going through the bone into where it wanted to be."
Bailes is confident that there will be positive results for Carol Poe.
"Well, we hope her sensation is a sensation of satiety, a sensation of fullness, a lack of compulsion to consume excess calories," said Bailes. "And a sensation again of satisfaction, of not having … the feeling we need to eat some more when we know we don't."
Three weeks after the surgery, the voltage inside Poe's brain pacemakers was turned on. According to doctors, it will be several months before any weight loss is noticeable once the voltage is increased to the level required.
Yet four weeks after the surgery, Poe said she's already lost three pounds.
"When I eat, I get full faster," she said. "I just don't have the cravings like I used to have."
And she said she no longer has the urge to consume a whole liter of her favorite drink -- Pepsi -- every day.
As part of the study, Poe must keep a meticulous journal of everything she consumes, and doctors will carefully track her progress. If this proves to be the solution to what has been a lifelong struggle for Carol Poe, her surgical team believes it could and should become widely available, targeting the brain for the benefit of the body.
"If I have a craving it's just a little craving and it's not just a craving to keep eating and eating and eating it," she said. "My body feels different. I feel like I am more, I'm more satisfied as far as food goes. And … I feel better."
"This may be the tip of the iceberg," said Bailes, "And again open the door for clever people and brilliant researchers to look at what the other applications could be. I think we can't forsee some of those now."