DrWatkins

We have now done plication on four patients that previously had gastric bands. They mostly like the fact that the fullness is abdominal and not high in the chest and that you don't need band adjustments and there is no port. They like that they will never require an urgent unfill from getting too tight. We also know that the plication, like any other procedure, is best to think of as a tool for weight loss and works best in conjuction with making good food choices and adding some type of calorie burning to the mix. Regarding emotional eating, this is a complex subject and even skinny people have emotional eating and there are literally hundreds of books written on this subject, but the best book on emotional eating I have seen so far is Dr. Gould's book, "Shrink Yourself". Dr. Gould is a psychiatrist who has worked with weight loss patients for nearly 30 years in California. I learned a lot by reading his book. Basically, he helps us identify possible things in our past that might be creating "phantom hunger". It is a pretty intense book and not everyone likes it but I haven't found anything that does a better job of really understanding the kind of emotional eating that interferes with successful weight loss. It is also easier to read than many books on this subject. Brad Watkins MD

Regarding acid reflux, this is most commonly caused by a hiatal hernia. Hiatal hernia is when the opening in the diaphragm (breathing muscle) for the esophagus (swallowing tube) is too big. Being overweight contributes to hiatal hernias because of chronically elevated intra-abdominal pressure. One thing I have learned after doing weight loss surgery exclusively for 8+ years in thousands of patients is that every overweight patient has a hiatal hernia and this must be addressed to minimize problems with weight loss surgery. At best we find the hiatus dilated and needing to be strengthened with suture. Many surgeons don't address this at the time of the weight loss operation and this causes a lot of problems down the road. What I have learned is that you have to look for the hiatal hernia - it is not obvious. What I mean by that is that you have to dissect out the diaphragmatic crura at the time of surgery. (The crura are muscular pillars around the esophagus). This opening is supposed to be about the size of a quarter (coin). We frequently find it the size of a small lemon and they can get really big, sometimes nearly the size of a baseball. Hiatal hernias are simple to repair by stitching the defect down to the proper size. The other issue to prevent acid reflux is to make sure part of the esophagus swallowing tube is down in the abdominal cavity. Frequently, in overweight patients, 100% of the esophagus is up in the chest and there is no anti-reflux mechanism. With part of the esophagus down in the chest, this will help prevent acid and bile from shooting up into the esophagus. The stomach lining can handle acid and bile. The esophagus cannot. Acid and bile can burn the esophageal lining which hurts and can even form cancer if left untreated for a prolonged period of time. The process of dissecting out the diaphragmatic crura and repairing the hernia at the time of surgery enables you to mobilize intra-abdominal esophagus and not only stop acid reflux disease but prevent it now that the stomach is much smaller in size. Most surgeons ignore the hiatal hernia which is a problem. The other thing I see is improper suture being used or trying to tie the knots across a diagnonal instead of straight across and using interrupted instead of figure-of-8 suture. Like everything in surgery, there is a proper way to repair hiatal hernias which reduces recurrence. Some large hiatal hernias require a mesh patch and there is a proper way to do this as well. We've done nearly 5,000 band surgeries over the past 8+ years and repairing hiatal hernias has done many wonderful things for band patients. Not only does the hiatal hernia repair stop their acid reflux, it also gives the band a nice sweet spot and allows us to tighten the band enough for weight loss without reflux. Far too often, surgeons ignore the hiatal hernia with weight loss surgery or they repair it improperly and this causes much frustration and the potential for revisional surgery down the road. As you can imagine, the best time to do perfect surgery is the first time. A routine part of my plication procedure is to address the hiatal hernia properly and this maximizes weight loss while minimizing patient frustration and inadequate weight loss. If a surgeon ignores the hiatal hernia with a plication surgery, the patient will have terrible heartburn and be very frustrated with eating and weight loss. I meet surgeons at meetings who argue that the hiatus is not that big of a deal but my experience is that it is a crucial part of a happy patient losing weight happily. Brad Watkins MD

Indeed the sutures (stitches) we use are third generation synthetic silk sutures (Ethibond) and they do create a reaction which is stronger than the stitch alone which is a good thing. They are reversible, however, because you can separate them surgically. We know this because we do it all the time with band revisions. We use the same suture the same way with band surgery and we have the luxury of knowing what these look like many years later and we know that we can reverse them because we do it all the time during band revisions. The simple answer is that it is indeed reversible. The more complex answer is that it would take a surgery to reverse it and it would be a process to separate each suture and the reaction around it. I think it is also important to note that patients who have weight loss surgery do not want it reversed! The reality is that it is quite the opposite - patients would never consider having it reversed. It is comforting, though, to know that if you ever wanted or needed your entire stomach, it is still there and still functioning normally - it's just smaller so that you can lose weight without feeling deprived or starved. Brad Watkins MD

Indeed all the names mentioned are in essence the same procedure. Since this procedure is not associated with a manufacturing company like the gastric band, different surgeons are applying different names to it and that is confusing indeed. Regardless of what surgeons call it, the thing to make sure is that the stomach is being imbricated (folded in on itself in multiple layers) and then stitched (sutured, plicated) so that the end result is a smaller stomach capacity. I think adding the superlative, "super", to it is confusing and seems to imply that the resulting sleeve is really small. Even with stapled sleeve gastrectomy (a different procedure), there is no agreement as to the size of bougie (sizing tube) used to calibrate the volume of the sleeve. The cool thing is that patients lose weight really well across a wide range of bougie sizes. Like all other weight loss operations, they work best when patients are making good food choices (not eating ice cream everyday, etc) and are burning calories (walking, etc) since all weight loss comes from caloric deficit (burning more than consuming). To my knowledge, in addition to our Cincinnati and Chicago clinics, plication procedures are offered in Salt Lake City (Dr. Cottam) and Tampa, Florida (I don't know the name). Dr. Ponce in Atlanta has contacted me and is interested in doing the procedure. When I spoke with him last he was planning on offering this but wasn't offering it to the public yet. Cleveland clinic was part of a clinical trial but the trial is closed and I don't know if they offer it outside the trial. Several weeks ago, I flew to Salt Lake City to watch Dr. Cottam do a plication procedure and we had great discussions comparing our experience with plication procedures. We have developed a clinical advisory board so that we may pool our experience in a single database and have an outside (non-biased) surgeon review our results and make sure these procedures have the same oversight as a formal clinical trial. This kind of oversight is common to new devices and sponsored by industry, however, plication has no device and therefore no industry involvement so Dr. Cottam and I are footing the bill for this. To my knowledge, no other surgeon has ever created an advisory board for a new procedure like this before. Suffice it to say, Dr. Cottam and I are extremely interested in doing this properly and learning from each other. I don't see that we are going to see any major surprises with the procedure over the years. The main thing I imagine is that, like all other weight loss operations, the plication might dilate to the point that it is not as effective of a weight loss tool. If this happens, one could place more stitches, band the sleeve or any other weight loss operation since the stomach is still there and no bridges have been burned. The best way to prevent dilation is to not drink carbonated beverages and not eat to the point of regurgitation every day for months. Dilations are chronic, they do not happen after a single event. I hope this adds some clarity to a new procedure. I like the plication a lot and I think it will be a really big deal as more people learn about it. I also imagine that it will someday be covered by insurance but that might be ten years away because they like to see lots of data. Brad Watkins, MD

Regarding the reversibility of the plication... The simple answer is that, yes, the plication is reversible. The more complicated answer is that it is not as simple as removing a hem and the fabric falls apart. The stomach is a wonderful living organ and we use third generation silk suture (Ethibond) that causes a little scar reaction so that the result is stronger than the suture alone. Now, I don't imagine we will have people wanting to reverse the operation, but if someone did, the process would be to remove each stitch (laparoscopically) and that would take some time and there would be a risk for stomach perforation (small risk). If surgeons used Prolene suture (looks like fishing line), it would be easier to reverse but that is the problem. I've already seen reports of Prolene plications falling apart and the surgery has undone itself soon after the operation (not good). Also, the imbrication and plication describes the same procedure where you stitch the stomach smaller with no stapling and no cutting. The good news is that your stomach is still there and you haven't burned any bridges - you could still have any other procedure down the road. Hope that helps. Brad Watkins, MD

Left shoulder pain after surgery is a common symptom and a common question. Basically, left shoulder pain is a referred pain from the diaphgragm (breathing muscle between the chest and abdominal cavity). If the diaphragm has inflammation the brain feels this in the left shoulder. The reason for this is called referred pain. If the brain can see something, it learns pain signals very quickly and easily and can localize it precisely. If you were blindfolded and someone stuck a pin in your finger, you could pinpoint the exact finger and location because your brain has learned these pathways. If something hurts inside the abdominal cavity this is a different story. The brain "feels" the pain where it thinks it is coming from. The reason the brain thinks that diaphgram pain is coming from the left shoulder is because of the phrenic nerve anatomy. The phrenic nerve is the nerve to the diaphragm and it doesn't enter the spinal cord down low where the diaphragm is, it enters the spinal cord up high at C4 (fourth cervical vertebrae in the neck). This is a great design because you could break your back and spinal cord nearly along the entire length and still not require a ventilator. Now, Christopher Reeves (Superman), broke his neck above C4 when he fell off the horse so he had to have a ventilator - his diaphragm was paralyzed. Therefore, when the diaphragm is the source of pain, the signals are carried to the brain up the phrenic nerve to C4, the same location the shoulder nerves enter the spinal cord and the brain says, "Hmmm, the shoulder area is sending pain signals, the shoulder must be hurting." This is referred pain. It feels truly that the shoulder is hurting but the source is the diaphragm. This is very common in all laparoscopic surgery. It is also common in spleen injury, with blood under the left diaphragm, patients have left shoulder pain (Kehr's sign). The main reason to explain this is that you don't have to stand on your head or do funny positional things to "get rid of the gas". We use carbon dioxide gas which is the most diffusable gas there is so the body gets rid of it very quickly and easily. Left shoulder pain is not due to "gas left inside"; it is related to diaphragm inflammation from surgery. When you exhale, CO2 comes out of your bloodstream into the lungs and out. Think of carbon dioxide (CO2) like Casper the ghost - it could go through walls easily, it is very diffusable. I hope this adds clarity to an interesting phenomenon associated with laparoscopic surgery. Brad Watkins MD

Even though we don't have long-term information on the plication, we have placed the exact same sutures on the stomach for many years so we certainly know how they behave over the long-term. Based on our extensive past experience, I believe strongly that our sutures will hold strongly over a lifetime. I also believe that like any other weight loss operation on the stomach that a small percentage of patients will have dilation years later with weight regain. In that instance, we could place more stitches laparoscopically (tiny incisions) or you could band the top of the sleeve or you could have any other weight loss operation for that matter - plication doesn't burn any bridges - you still have your stomach. It's worth mentioning that I've already seen quite a variation of the stitches being used and that does make a difference. In my opinion, the best way to do the plication is to perform two layers of running 2-O Ethibond suture and then place interrupted stitches to reinforce the outer layer. You don't need to reinforce the inner layer because it will remain beneath the outer layer. I've seen surgeons having trouble with Prolene suture coming undone so I would not recommend this. Prolene doesn't hold it's knots as well and does not cause any reaction from tissue. I've read reports of Prolene stitches coming undone and the patients therefore report zero restriction shortly after the surgery and it has to be redone. Ethibond is a third generation silk suture and it is intentionally designed to cause a reaction with the tissue that creates a little scar tissue at the stitch which makes the bond stronger than simply the stitch. On the outer layer, if you do this as a running (continuous) suture and then reinforce it with interrupted stitches, the plication looks really perfect and is quicker to do (less anesthesia time). Then, the interrupted stitches are easy and quick and you've got redundancy which should make the possibility of it coming undone as near zero as we can get in human healthcare. Brad Watkins MD

Regarding "fishing line" sticking out of incisions, those are the "tails" of the knots tied in dissolving stitches that are commonly used in surgery. The best advice is to show your surgeon. The options are to leave them alone - they will eventually dissolve. Also, your surgeons office can trim them level with the skin which will reduce the annoyance of them getting caught on clothes, etc. Brad Watkins, MD

Regarding total calories, many patients losing weight will be around 800-1200 calories per day. Ideally, women shouldn't go below 1200 calories and men 1400 calories. Below this we think the body starts shutting down fat burning as a survival mechanism. Remember that ALL weight loss comes from calorie deficit (burning more calories than you consume). The best weight loss comes from adding more burned calories to the calorie reduction that comes with any weight loss operation. Self-monitoring (tracking eaten calories against burned calories) is a very powerful weight loss tool that has proven effectiveness. The Internet has many self-monitoring tools for free (www.FitDay.com; www.livestrong.com - the Daily Plate; etc). Also, the iPod app "LoseIt" is very helpful. There are many of these free self-monitoring applications out there. Even with weight loss surgery it is hard to starve your way into a calorie deficit. Adding even a little calorie burning can be a huge help - even walking briskly for 30 minutes per day can add a lot of weight loss. I put a bunch of weight loss lectures on YouTube if you search Watkins Weight Loss Class for even more detail on all this stuff. Brad Watkins MD

Ghrelin, the hormone, gets a lot of attention these days. Here is what we know about ghrelin: Ghrelin is one of many hormones involved in appetite. We are learning that appetite is a very complex system and part of our body's survival mechanism. The brain wants us to breathe and eat - these two items are at the top of its list! The drive to eat is a very powerful biological drive. Ghrelin is a feedback hormone and pressure in the wall of the stomach is what suppresses it. In other words, when you eat, the food activates pressure receptors in the wall of the stomach and ghrelin levels go down. If you haven't had the pressure receptors in your stomach activated for a while, ghrelin levels rise and so does hunger. The most important way to suppress ghrelin levels is PRESSURE. Cutting out stomach that produces ghrelin doesn't eliminate ghrelin. The parts of the stomach that are left can produce lots of ghrelin but if there is pressure (food in the smaller stomach) then ghrelin levels will be low. After gastric bypass, ghrelin levels go way down even though the entire stomach remains. After Lap Band surgery ghrelin levels are suppressed in general and get low after eating and the food creates PRESSURE in the small gastric pouch. It is the pressure reducing these levels since the entire stomach is still there. Keep in mind that the ghrelin levels are a small part of a very complex system. When you talk to plication patients they have reduced appetite particularly after a small meal since the food creates pressure and activates the pressure receptors in the wall of the stomach. There are probably many pharmaceutical companies working on an "anti-ghrelin" drug but it is likely that even if such a drug is created and works, the other hormones involved in appetite will increase over time reducing its effectiveness. All this to say, the best way to reduce appetite is to stretch the wall of the stomach and if a stomach surgery has been done to reduce its size (band, bypass, plication, stapled sleeve, etc, etc) then you will get appetite reduction on smaller calories. One of the reasons weight loss operations work so well is that you are reducing appetite through normal biological channels, not a drug with side effects and decreased effectiveness over time. Many people worry about ghrelin levels. The important question is, "does the operation reduce appetite?" If the answer is "YES" then you have a very powerful operation for weight loss regardless of ghrelin levels. We know that weight loss operations are suppressing things that float around in the blood stream that are yet to be discovered. Vince Lombardi once said, "I don't give a #$&%! about statistics as long as we WIN!" Brad Watkins MD

We do the plication using all 5mm laparoscopic incisions (tiny). If a surgeon uses any 10mm instruments this would require 10mm scars so you should ask your surgeon about the size of the incisions. For example if you do stitching using simple surgical instruments this only requires 5mm incisions. There is a commercial device that some surgeons use (EndoStitch) that aids suturing but this is uncecessary if you are comfortable with laparoscopic stitching using standard laparoscopic instruments and it requires a 10mm incisions. For Lap Bands we use a cosmetic approach by hiding the port scar in the umbilicus(belly button) and 2 addition 5mm incisions. This technique makes it very difficult to tell any surgery was done. The plication involves a total of five 5mm incisions. For free weight loss classes, I have put a series of weight loss lectures on YouTube that would be helpful for anyone desiring to lose weight. If you search "Watkins Weight Loss Class" they will pop up out of order. To find them in order, you have to add the next number to the search (ie 1,2,3,4, etc) Brad Watkins, MD

Another common topic of discussion is the hiatal hernia. What I have learned from doing weight loss surgery for over 8 years now is that all overweight people have a hiatal hernia. The hiatus is the opening in the diaphragm breathing muscle for the esophagus swallowing tube. This is supposed to be the size of a quarter (coin); we often find it to be the size of a lemon and this needs to be repaired. The repair is easy as you simply stitch the muscular opening down to the appropriate size. What I have learned is that you don't often see these hiatal hernias at the initial surgery because they contain ("extra padding tissue that is yellow in color"). To be thorough you have to go looking for them and if you go looking for them (hiatal hernias) you will find them and they need to be fixed. Hiatal hernias cause heartburn (GERD, acid reflux, etc). When you do any opertion that restricts the volume of food as most weight loss surgeries do, the plication being no exception, you must repair the hiatal hernia even if it is small. If this is ignored (not repaired) the patient will have severe heartburn after the procedure which causes frustration, additional medications and interferes with successful weight loss. I am a radical proponent of fixing hiatal hernias. Many surgeons don't agree with me and only fix large hiatal hernias which are evident on visual examination. Most surgeons that have experience with weight loss operations for more than a couple of years have learned the importance of fixing hiatal hernias (in every surgery). Therefore, a routine part of my plication surgery is to repair the hiatal hernia. It is right there in the same are where we are working, it is easy to repair and creates happy patients after surgery. The best time to do perfect surgery is the first time. Brad Watkins MD

There was a question about a measuring catheter used during plication surgery. This is likely referring to the "EndoFlip" which is a commercial measuring catheter used for multiple purposes. My opinion is that this is unecessary for plication surgery. The idea is not to make the stomach tube too tight or too loose. This can be accomplished using a surgical bougie (pronounced "BOO - gee"), which is a long soft rubber tube that comes in different sizes. Surgeons have not agreed on the perfect size bougie yet but the sizes surgeons use are around 32Fr ("French" - a diameter sizing system). What I like to do is to perform an EGD (esophago-gastro-duodenoscopy - a scope of the stomach) in the operating room just prior to the surgery to make sure the stomach is normal and healthy and there are no polyps or ulcers, etc. Also, the scope is 32Fr so I simply leave it in place and use it as the measuring device and then I can examine the gastric tube I have made at the end of the procedure. This also eliminates blind intubation of the esophagus and stomach and avoids multiple tubes being passed into the esophagus and stomach and this will reduce the chance of any injury due to blind intubations. We have done 7 cases now with this technique so my opinion is that no additional costly measuring devices are needed. The beauty of plication is that you are just using stitches which are relatively inexpensive and that is why the cost of the surgery is so much less. You certainly don't want to add additional expense unless it adds a marked advantage. Brad Watkins MD

Regarding questions about the history of plication, it seems to have started in India as a low cost alternative to band and stapling procedures. It has also been done in Greece, Brazile and Mexico with everyone reporting essentially the same results - about 60% EWL (excess weight loss) at one year with no evidence of regain so far although the data is young (not a lot of long-term data). There was a clinical trial with 45 patients from Brazil, Cleveland Clinic and OSU. The trial is closed but ongoing data is being collected. We have now completed 7 cases in Cincinnati with several more scheduled. I'm going to spend time with Dr. Cottam in Utah next week to watch him do cases and compare our experiences with the new procedure. I haven't seen nausea be a big problem post-operatively but I read about this a lot from the small number of published papers. The biggest thing I see early after surgery is that some patients have difficulty drinking liquids for a short time until the swelling goes down. I've had one patient that required intravenous fluids for one day since he wasn't able to drink enough with the swelling. This patient is already down 40 pounds in about 6 weeks. I think it is important to eradicate the "stomach bacteria" (Helicobacter pylori) prior to surgery and continue PPI's (Prilosec, Nexium, Prevacid, etc) for 2 months post-op. I have patients do 2 weeks of liquid Protein to shrink the liver pre-op and do one week of liquidy food (think applesauce consistency) post-op and then 2 weeks of soft mushies and then on to regular food. Originally, I thought that plication patients could drink with meals but I am already finding out that it's best to drink before meals and once you eat solid food, wait for at least an hour prior to drinking again. This allows you to be full on much smaller quantities of food. Always keep in mind that all weight loss surgeries are tools for weight loss and work best in combination with the patient's good efforts. Also, all weight loss surgery tools work best when combined with calorie burning. Calorie burning doesn't have to be sophisticated - even walking is an excellent way to burn calories. All weight loss comes from calorie deficit - burning more calories than you eat. Therefore, adding calorie burning to the help of calorie reduction with surgery is the best way to lose weight. I've put a bunch of medical weight loss lectures on YouTube if you search "Watkins Weight Loss Class" it will pull them up and hopefully help in the pursuit of weight loss success. Brad Watkins MD

Gastric plication and gastric imbrication are describing the same operation. The ROSE procedure is an endoscopic stitching for gastric bypass patients that have regained weight due to stretching or dilation of the connection between the gastric pouch and the small intestine. As opposed to the sleeve gastrectomy whereby the stomach is made into a tube using staples (and the stomach is removed), the plication (or imbrication) creates a sleeve by folding the stomach in on itself and then stitching to keep it folded in on itself. Your entire stomach is still there, it's just folded in on itself with stitches to keep it there. No staples. No cutting. No stomach removal. I have not seen ghrelin studies on gastric plication but plication patients do describe profound appetite reduction and they get full on small amounts of food so it appears to be a very good weight loss tool. Ghrelin reduction comes mainly from pressure, stretching the wall of the stomach, which occurs when the stomach volume is smaller. Ghrelin appears to be a small part of a very complex appetite mechanism of which we only have the most superficial understanding. In my mind the only downside to the plication is that we just don't have that long-term data with hundreds of thousands of patients over ten to twenty years like we have with the bypass or the band. There is two year data out of Brazil that shows plication weight loss in the 60% excess weight loss at 2 years which compares favorably to other successful weight loss operations. We performed our 5th plication this morning. Three were band patients that converted to plication and two were primary plication patients (plication done as the original operation). To date, I have been very pleased with the satiety the plication causes and the associated weight loss. We call it the GPS (Gastric Plication Surgery). GPS is very different from the VBG (vertical banded gastroplasty) from years ago. VBG was simply stapling a small pouch in the upper part of the stomach. GPS (plication) creates a small tube out of the entire length of the stomach. Hope that helps Brad Watkins MD Gastric Plication Surgeon Cincinnati, OH