DrWatkins

You should know that one of the perforations due to gastric necrosis happened to one of my patients. I have since contacted many bariatric surgeons to inform them of this and in doing so learned that there have been several other cases in other clinics as well, some of whom had their surgery outside the U.S. As soon as I learned this I posted the information on this forum as well as our plication patient's private message board. Will I continue to recommend plication surgery? The short answer is not right now. Regarding full length plication as a primary operation I think we need more information on why some patients are developing gastric necrosis and some are not. We've had many successful plication patients with excellent weight loss. Certainly perforation is a known potential complication of stapled sleeve gastrectomy as well, but considering that relatively small numbers of plications are being performed around the world, a few perforations is too high of an incidence for me especially given the magnitude of the complication. When a perforation occurs in a plication, this stomach has to be removed, the end result of which is essentially a stapled sleeve gastrectomy. One of the things that attracted me to the plication is that it seemed like it would avoid the possibility of perforation since there were no staple lines. These perforations are occuring through a different mechanism - compromised blood flow to the stomach. In speaking with many bariatric surgeons in the U.S. we would not have anticipated this based on our knowledge of the stomach's blood supply. We do not think this is an arterial problem (inflow of blood) - it seems to be a problem of venous congestion or impairment of venous drainage in the crowded stomach. In simple terms, if the venous blood can't flow out of the tissue, this ultimately impairs the arterial inflow of blood from coming into the tissues. The end result is necrosis of the tissue which can perforate. This is the best theory we have currently on why this has occurred. It is possible that a much looser plication or a single row plication instead of two rows might prevent this from occurring but would likely also reduce average weight loss success. An early study in a small number of patients at the Cleveland Clinic showed that anterior plication (only plicating the front part of the stomach) had disappointing weight loss results and they subsequently abandoned the technique. It is likely that tighter plications have better weight loss but higher risk for perforation and a looser plication might reduce the chance for perforation but also reduce weight loss success. We have not had the experience that necrosis shows up later in the post-operative course. If you currently have a plication consult or surgery scheduled I would recommend that you discuss this with your surgeon. If I learn additional important information I will post it on this forum.

After speaking with bariatric surgeons around the country I have learned about several reports of perforation due to gastric necrosis in patients that had plication surgery. These patients have presented within the first few days of surgery and complained of severe abdominal pain. To my knowledge, there are no reports of this presenting beyond the first few days after surgery. What is unclear is why this occurs in some patients and not others. The issue appears to involve impaired blood circulation in the crowded stomach tissue that has been folded in on itself. The cardia portion of the stomach (the upper part) seems to be susceptible to this. Since plication is a new procedure, at this stage it is important to know about this as a potential complication. I will continue to post updates on this forum as we learn new information.

Last week was the MISS Conference (Minimally Invasive Surgery Symposium) in Salt Lake City, UT . The first part of the week is laparoscopic general surgery and the latter part of the week is the bariatric surgery section. There was a lot of enthusiasm and interest surrounding gastric plication. It is now a hot topic on the agenda of these meetings and the interest is growing substantially. There was a GPS course at the meeting and surgeons advertising future courses at their institutions. We have begun GPS training courses as well. There are a lot of surgeons wanting to learn how to do GPS and offer it to their patients. The GPS is still considered experimental/investigational since there is no long-term data in the U.S. There is longer-term data internationally that looks good and a couple of surgeons in the U.S. like us are seeing good weight loss averages with the procedure but it is certainly an early stage technology. There were surgeons at the meeting who felt that this procedure looks promising but is not ready for prime time yet due to the absence of long-term data and there were surgeons like myself at the meeting who have experience with the procedure and have successful patients and we feel it is a good operation with the caveat of long-term data. What I see is that patients are driving the interest in GPS because it doesn't involve implants, staples or intestinal malabsorption. It is wonderfully simple - it's just your stomach, only smaller. I have also been fixing plication cases done by other surgeons so I feel strongly about proper technique. I will keep you updated as we gain information on this new procedure.

My opinion is that the only magic to it is simplicity. We have tried plans in the past where you do one or two protein shakes per day and eat small healthy meals but all of those plans we tried, the livers were huge during surgery. I think that in many cases, patients would just eat whatever they wanted or they would eat their regular meals and add the shakes on top of that so we were probably increasing calories before surgery and not decreasing. In my experience, if a patient does liquid protein fast only, the liver is drastically reduced making the surgery easier which makes your recovery easier. For a time, I started waiving this requirement in lower BMI women, but those cases ended up being the most difficult cases we were doing because of the liver so now we basically have everyone do it and the results are excellent.

Yep. What I have found is that one week of liquid protein fast is all that is required for female, no diabetes, BMI<45 but the best advice is to always follow your surgeon's instructions. Over the years we've tried a bunch of different things pre-op to reduce the size of the liver and by far the thing that works best in my experience is liquid protein fast - i.e. you drink 3-4 Protein shakes per day which total about 800 calories. It never hurts to do it longer and lose a bit more but those are the minimums. In the pre-op room, when I ask how the liquid protein diet went, if patients say they hated it, I typically find a small liver during surgery. If they tell me it wasn't that bad, watch out for a big liver (usually means they didn't stick to it very well). In extreme cases you simply can't do the surgery or you really struggle with the liver. The most dramatic liver size you see is in men, BMI>45 and diabetes. In some cases I'll have diabetic males with BMI>60 do three weeks of liquid protein fast. We always want the surgery to be as perfect as humanly possible. There are some things we can't control but liver size is one we can.

The main purpose of the pre-op diet is to reduce the size of the liver making the operation easier and quicker. The liver loves to store extra calories. Steatosis is the medical term or "fatty liver". Fortunately, the first weight you lose comes out of the liver reducing the liver size very significantly. There are other benefits to pre-op weight loss such as making it easier for the anesthesiologists to place the breathing tube and it improves your cardiovascular function, but the main reason is the reduction in liver size. This becomes critically important in men, patients with diabetes and BMI>45. Females with BMI<45 and no diabetes have the easiest livers to deal with and for these patients I only ask them to do one week of liquid protein fast as that is all that is required to reduce the liver size. Brad Watkins MD

We have developed abnormal relationships with food. We eat to cope. We eat when we're bored, happy, sad. Food can be a lover, a friend. The biggest problem with this is that food works really well and really quickly in these situations and we gain weight. If we only ate when we were truly hungry we'd all be thin. We also train ourselves like dogs to be hungry all the time. This is not true hunger. This is phantom hunger. If we eat in the mini-van, in front of the computer or in our chair in front of the TV, what this does is that every time we are in the mini-van, in front of the computer or in our chair in front of the TV, we are HUNGRY. This is not true hunger. This is phantom hunger and we've gotten really good at it. A major help is to only eat at the table so that it is the only thing associated with food. If you go up to a dog and say, "wanna treat?" they will go absolutely bizerk because they associate this with food coming in. There are many terms for phantom hunger - emotional eating, mindless eating, non-hunger eating, etc. This is the hardest thing to solve. The keys are to recognize our triggers and to identify sources of deep-seated psychological pain and address them so the phantom hunger will go away. The best book I've seen on this is called "Shrink Yourself" by Dr. Gould. True hunger is a physiological NEED for food. It is patient. Any food will do. There is no associated guilt or shame. Phantom hunger is a DESIRE for food. It is impatient. There is a specific craving. ("If I don't get chocolate right now I will harm somebody" etc.) It is a reaction to a stimulus. It is associated with guilt or shame. The easy test to see if you suffer from phantom hunger is if you can't stop yourself. Phantom hunger is the most complicated aspect of weight gain and therefore the hardest part of successful weight loss. It comes from many different things in each one of us. We all have this. Skinny people have phantom hunger but they control it. A great example in Dr. Gould's book is an overweight woman whose life's dream was to get paid to sing. Unfortunately, in high school, a boyfriend made fun of her singing and this hurt her deeply emotionally. Every time this psychological pain came up, she ate. She struggled to lose weight. When Dr. Gould identified this and encouraged her to sing again, she finally agreed to sing at a friend's wedding and she received many positive accolades after. This led to a job as a music teacher in an elementary school - she was getting paid to sing. Guess what? She lost weight successfully. She solved the source of deep psychological pain and therefore eliminated the source of phantom hunger. Another example is women who were sexually abused as children. Food treats the pain and obesity is an outer protection against abuse. This is very difficult to deal with alone and typically requires the help of a professional to bring this to the surface, deal with it and treat the source of psychological pain and phantom hunger. You see similar situations in unhappy marriages and basically any source of real stress. The secret in all these things is to deal with the source of pain and also find non-food ways to cope with them. All this is easy to say. This is the most difficult aspect of weight loss. Finding a psychology professional that deals specifically with weight loss can be helpful to tipping the scale in your favor. An interesting test in Dr. Gould's book is to ask yourself who you are jealous of and why. He sees many patients who can't pinpoint their source of psychological pain so he asks them who they are jealous of. This is how he identified the source of pain in his singing patient when she told him she was jealous of a friend who was paid to sing. This is a tiny amount of information on a very complex topic. You can do the nutrition and fitness stuff perfectly and still not lose weight if there are issues in the brain stuff category. Ask yourself if you suffer from phantom hunger and if you have difficulty stopping yourself. Consider working with an expert or reading Dr. Gould's book. Positive self-talk is another important topic in this discipline and I go into detail on this and more on YouTube. Search Watkins Weight Loss Class. I hope this is helpful. Weight loss surgery makes all this stuff much easier but it is still important to be smart in the disciplines of Nutrition, Fitness and Brain Stuff. I wish you all the greatest success in your weight loss journey. Remember the importance of buying yourself a really nice present when you reach your goal. Brad Watkins MD

All weight loss comes from calorie deficit (burning more than eating). It is very difficult to starve our way into a calorie deficit and the body is designed to fight this with a vengeance so a major secret to successful weight loss is to add calorie burning in any way we can. I see many frustrated patients who are "doing everything right and not losing weight" and we find that the culprit is little to no calorie burning. Often, simply adding a brisk 30-minute walk per day tips the balance into calorie deficit and this converts a very frustrated patient into a patient happily losing weight. Calorie burning doesn't have to be complicated or sophisticated it just has to consistently happen. A great tool for this is a pedometer which you can buy very inexpensively. You want to shoot for 10,000 steps per day. You want to look for any excuse to burn calories: park farther away, take the stairs, etc. ADL's (activities of daily living) burn far more calories in a given day than going to the gym. You may sweat for an hour on a treadmill and burn approximately 300 calories but you'll burn much more than that just walking around during the day going about your normal business. All that to say, if you add simple little things throughout the day like parking farther away, etc these burned calories will really add up and will increase your chance of acheiving a calorie deficit and you will lose weight without the frustration. The majority of our "metabolism" (BMR - basal metabolic rate) comes from muscle mass. As we get more active and more fit, we actually increase our muscle mass which increases our metabolic rate which burns calories while we're sleeping. This allows us to lose weight more effectively and allows us to eat more and still lose weight. The cool thing is that if you go for a brisk 30 minute walk you not only increase your metabolic rate while you're doing it but this continues for a long time after you get done. The benefit goes way beyond that 30 minutes of your life. Guys lose weight faster because of higher testosterone and higher muscle mass. One of my research interests is looking at testosterone levels in men AND women. I've seen several men with low testosterone levels and we treat this and it helps them lose weight. Same thing in women. Obviously women have much lower testosterone levels, but I've seen several women with zero testosterone (or really low) and we replace it to normal female levels and it helps them lose weight. The most common question I get is, "what is the BEST exercise?" The answer is, the one you will do. If joining and regularly using a gym is just not realistic, but walking 30-minutes per day with your pedometer is realistic then walking is your best exercise. I've had patients lose 250 pounds walking on a treadmill. I've had two patients lose over 100 pounds with a Wii Fit. Some patients like exercise videos and DVD's. Some patients like these exercise bands (big rubber bands with handles). Some patients start taking their dog for a walk. If you're burning calories then you're doing it right. Find something you enjoy and something that is realistic for you to sustain and you'll see the results. I have a patient who works in an office building on the first floor. Every time she needs to go to the bathroom she takes the stairs to the fifth floor. She acheived phenomenal weight loss success just by using the stairs to the fifth floor bathroom. It doesn't have to be sophisticated, it just has to be consistent. Swimming pools are a great way to burn calories because you not only burn calories with the muscle activity, your body burns calories to keep your body warm. Our core body temperature is about 98.6 degrees and most pools are much cooler than that so our body burns calories to keep the core temperature up. Even walking around the pool is a great calorie burn and this is also a great way to keep weight off inflammed joints. Find your favorite way to burn calories. Be consistent with it. Take a brisk 30-minute walk at least once per day. Watch the scale go down. I hope this helps. I put this and much more on YouTube. Search Watkins Weight Loss Class. Brad Watkins MD

Since all weight loss comes from calorie deficit (burning more than eating), the key to all successful weight loss is to create a calorie deficit. There are many great tools to help track this and most of them are free. My favorites are the iPhone app, "LoseIt"; www.FitDay.com and www.Livestrong.com go to Calorie Tracker and myPlate and create an account. These programs track your deficit and help point out areas of improvement. In general, you should get about a third of your calories from each of the main food groups: Proteins, fats, carbs. If you see higher percentages of fats or carbs, replace those calories with Protein calories and it will really help you eat smarter instead of just less. Over the past 20 years we are eating many more calories and burning far fewer calories. The secret to weight loss is to work toward a calorie deficit whatever it takes. Most people losing weight successfully are eating about 1200 calories per day (women) and 1400 calories per day for men. Below this, your body tends to start freaking out and hanging on to everything you eat. It is also important to drink at least 64 ounces of Water per day. Our bodies store environmental toxins in the fat and when you lose weight, all this stuff is coming out and your kidneys will really appreciate it if you drink plenty of water. This helps battle constipation as well. Also, take a multi-Vitamin every day. The Calcium and B-Vitamins really help with weight loss not to mention the other minerals. Nutritional psychology is a hot new topic. Bad nutrition causes depression and low energy which makes us want to eat more to feel better and we snowball into bad weight gain. Better nutrition is required for successful weight loss and we feel better. Also, we eat way too much sugar and this raises our insulin levels which takes all that blood sugar and turns it into fat which drops the blood sugar which makes us hungry and we eat more sugar and this snowballs into weight gain. We eat way too much processed food and we have to get back to healthy foods. Brilliant food chemistry has not helped us. Cheap food sweetener (HFCS - high fructose corn syrup) is in everything now (sugary drinks, Pasta sauce, ketchup) and our bodies don't know what to do with this stuff so we store it as fat. We consume massive quantities of this stuff and it doesn't help us lose weight. High tech fats such as trans fats and hydrogenated oils allow foods to have a much longer shelf-life because bacteria can't break it down but the problem is that we can't break it down either and we just store it as fat. A great rule of thumb is that if it doesn't spoil we shouldn't eat it. The classic example is an oatmeal pie that our kids drop in the mini-van and we find it a year later and it still looks good. We shouldn't be eating brilliant food chemistry. The more we preare our own meals and take our lunch instead of getting most of our meals at restaurants, the easier it is to lose weight successfully. Proteins - we should get about 45gms of protein a day (women) and about 60 grams per day for men. A 20gm protein portion (meat, chicken, fish, etc) is about the size of the palm of your hand or a deck of cards. Protein keeps us full longer because it doesn't mess with insulin and we need protein while we're losing weight so that we lose fat and not muscle. Fats - are the highest caloric density food. Each gram of fat has twice the number of calories as proteins and carbs. Believe it or not there are actually "good" fats (unsaturated). You want to avoid saturated (bad) fats. Saturated fats raise our cholesterol and clog our arteries. Unsaturated fats actually lower our cholesterol. To lose weight, you should limit fat grams to 20 gms per day and keep saturated fats below 10gms per day. Trans fats and hydrogenated oils should be zero. All this is easier these days with nutrition labels. Examples of good (unsaturated) fats include avocados, peanuts, soybeans, olives and oils such as olive, canola, peanut, corn, safflower, sunflower. French fries from peanut or safflower oil are actually healthier than those fried in saturated oils - ask your restaurant which they use. Fats actually release a gut hormone called CCK (cholecystokinin) which causes the gallbladder to contract and it is a powerful natural appetite suppressant. If you give CCK to rat they won't eat. Therefore, if you snack on a handful of almonds or dip vegetable sticks in olive oil, you manage your hunger and it is healthier. Bison (buffalo) has a great beef flavor and it has much less saturated fat than cow beef. Bison burgers and steaks are a much healthier way to enjoy beef than the cows that predominate our diet. Carbs - when eaten shoot up the insulin levels which turn blood sugar into fat and this drops our blood sugar level which makes us hungry. If you want to lose weight you have to manage carbs (sugar, bread, potato, rice - "white foods"). I see a lot of patients who go all day without eating and then eat a huge pasta dinner before going to bed. This is a perfect way not to lose weight. Carbs are best eaten earlier in the day when you have a chance to burn off all that energy. Eating three meals per day will keep us out of intense hunger and we eat fewer calories overall. I don't like Atkins type diets simply because they are hard to sustain. Better to manage carbs - keep them below 33% of total calories and eat them earlier in the day. Ice cream is enemy number one for weight loss. A great substitute is to make your own fruit smoothies at home. It is a sweet dessert but it is fruit instead of sugar and fat. Many stores have smoothie blends so you just toss it in the blender with diet apple juice or plain yogurt and it's easy. Be careful and avoid sugar added smoothie blends. Just get plain frozen fruit or make your own from fresh fruit. Great way to spoil yourself and eat healthier. I will post topics on Fitness and Brain Stuff (I don't like terms like behavior modification) which are the other two main disciplines of successful weight loss. I put this info and much more on YouTube if you search Watkins Weight Loss Class. Weight loss surgery simply makes all this stuff much easier but knowledge plus change is where you will find success. I hope this helps. Brad Watkins MD

I agree that it would be nice to have surgery close to home. I will see Dr. Cottam at the meeting so I will see what I can do! After we had done a few GPS cases I flew to Salt Lake to watch Dr. Cottam do cases. I think the hospital where he works is the main difference in cost. Hospitals are very expensive. I am fortunate to work in a surgical hospital which is basically a surgery center with nice hospital rooms where we can keep patients overnight. It is much less expensive because of the differences in overhead. I also don't think we need the endoflip which saves a lot of money. Congratulations on having the biggest surgical meeting of the year in your town. Brad Watkins MD

GPS is a very hot topic in the bariatric surgery community and growing every day. I am now starting to train other surgeons on the procedure and the demand for this is increasing as patients request GPS and surgeons want to learn how to do it. I have visited several U.S. surgeons that also do GPS for the benefit of sharing information and maximizing our collective knowledge about a new procedure. We share information on a regular basis for the benefit of our patients. Last week I visited a prestigious academic center that has started offering plication as well. When we first started, our patients were having a hard time pronouncing and remembering terms like imbrication and plication so I asked my wife what we should call it and she suggested GPS for Gastric Plication Surgery because it was easy to remember. This term seems to have caught on and now I see even international surgeons use the term. There does not seem to be agreement about the bougie size (bougie being a soft rubber tube used to size the new stomach sleeve). I have a strong opinion that the sutures (stitches) should be interrupted (individual stitches with a knot tied at each location) as opposed to a running stitch (knot tied at each end of a long stitch taking many "bites" along the way much like sewing. With interrupted stitches, the tension is controlled at each knot. With a running stitch, the tension is not controlled and can get too tight and lead to stomach tissue necrosis and/or perforation which we have all read about on this board. Another part of this is not to place the suture too deeply. In surgeonspeak, the suture should be seromuscular, not full-thickness. I also have a strong opinion that the ideal stitch is 2-O Ethibond. This is a third generation silk that actually causes a bit of scar tissue (favorable) which makes the bond stronger than just the stitch itself. Ethibond has been around for many years plicating the stomach for other reasons and it holds really well. I have seen Prolene used which is a monofilament suture and causes no reaction and actually doesn't hold its knots as well (poor suture memory as we call it) which means the knots can come undone. I think Prolene is at too high of a risk for prolapse where the whole thing resorts back to the normal stomach size or even worse where only one section is herniated out and could cause problems. I also feel strongly that the sutures should be no more than 2-3 centimeters apart from one another. I've seen surgeons place their stitches much further apart and I think this again increases the risk for prolapse or the stomach herniated back out between the stitches. We've learned from doing thousands of band surgeries for the last 9 years the importance of a two week liquid Protein diet prior to surgery to reduce the size of the liver and improve the ease of the operation. The first weight you lose comes out of the liver. I also think it is important to eradicate the known stomach bacteria, Helicobacter pylori because it is ubiquitous, most of us have it in our stomach lining and it can cause ulceration, inflammation or swelling when surgery is done on the stomach. This is easily eradicated with a two week antibiotic regimen pre-op. I think it's important to stay on a liquid diet (pureed Soups, applesauce, Jello, pudding, yogurt) for the first week and soft mushy foods for weeks two and three. Carbonation is a bad idea in any stomach surgery for weight loss because it dilates our work. (Have you ever opened a dropped can of Coke?) The best weight loss is acheived when you avoid drinking liquids for an hour after a meal. This allows you to be fuller sooner and longer and really makes the tool of GPS more effective. We have found that Levsin (hycosamine) 0.125mg SL (sublingual - under the tongue) given pre-op and continued three times daily post-op dramatically reduces the crampy abdominal pain after GPS. This has really improved the patient experience with this surgery. I also use lots of numbing medicine (local anesthetic) during the surgery which dramatically decreases pain after surgery. I always scope the stomach during the operation to make sure we're not missing an ulcer or polyp or any other important pathology. I do this in the operating room because it saves doing it as a separate procedure and also the scope is the ideal bougie size so I leave it in for the sizing catheter and this allows me to look at the perfect sleeve I just created when we're done with the procedure. Many surgeons don't do a stomach scope and I worry about doing this with no knowledge of the stomach lining. There is a lot of debate about stapled sleeve gastrectomy vs GPS. One item of consideration I think is important is that stapled sleeve patients have a 9% incidence of Vitamin B12 deficiency. The stomach makes something called intrinsic factor that aids in the absorption of Vitamin B12. A distinct advantage to GPS is that no stomach is removed and the intrinsic factor levels are not disturbed so you would expect that GPS patients would not have such a high incidence of vitamin deficiency. Stapled sleeve patients are also deficient in several other Vitamins such as Iron, folate and Vitamin D. (Ref: Obesity Surgery 2011, Feb 21(2):207-11.) I think there are many advantages to leaving the stomach in the body - just making it smaller as a powerful weight loss tool. Ghrelin gets a lot of press but it is important to realize that you reduce ghrelin with pressure (food in a smaller stomach). Ghrelin is a feedback hormone so physically removing stomach doesn't eliminate ghrelin. You guys have seen me rant about hiatal hernias on this board and I continue to feel strongly about repairing this during the surgery. What I've learned is that if you are overweight, there is nearly a 100% chance that you have a hiatal hernia and even if this is small it should be repaired at the time of surgery. Otherwise, you will have terrible heartburn when your stomach is made smaller. I get calls from patients that had GPS elsewhere and they have terrible heartburn and their hiatal hernia was not addressed at the time of surgery and they are pretty miserable. This is avoidable. Hiatal hernias are really easy to fix at the time of surgery so my opinion is that there is little excuse for ignoring this principle. The latter part of this month, I have a major annual surgical conference and plication is now on the agenda of this meeting. All this to say, I think that GPS is here to stay and gaining in popularity. One of my GPS patients came in the office last week having lost over 70 pounds in less than six months and he is quite thrilled as am I. That is all the good stuff. To me, the main downside is that the procedure is still new and we don't have long-term data. Two year data out of Europe looks good but we don't have two year U.S. data yet. There is some interesting data from Germany showing dilations ten years after stapled sleeve gastrectomy and I think the GPS can do this as well. We know from other operations that the key to preventing dilation is to avoid carbonation and avoid eating to the point of regurgitation after the stomach is smaller. Whenever something new comes up with GPS I will post it on this board. I also thank you for teaching me. Your experiences that you post here educate all of us. Keep up the great work. I wish you all the very best of success in your weight loss journey. Don't forget to buy yourself a substantial present when you reach your goal. Brad Watkins MD

My recommendation would be to simply go to the emergency room or call 911. Since I didn't do your procedure, I don't know the details of your surgery but am simply giving general advice. The ER should do a contrast study (drink Water soluble contrast and take x-rays) to make sure there is no perforation or leak. The water soluble contrast is better than barium simply because it is less irritating to the peritoneal lining than barium if there is a leak. Keep us posted on your progress and I hope you get to feeling better soon. If anyone has urgent questions you can always reach me 24 hours per day through the answering service (513-939-2263). Brad Watkins MD