DrWatkins

We have done four cases of simultaneous band removal and plication. This can be done at the same operation. I also have a few cases scheduled where we are going to reposition the band (for dilated pouch) and leave it in place (deflated) and do a GPS. In this way, the patient will have a GPS and a deflated band in place. In this way, if needed, the band could be adjusted in addition to the GPS. Brad Watkins MD

We have done GPS (Gastric Plication Surgery) on several patients who were previously banded. One important difference is that GPS fullness feels like normal stomach/abdominal fullness. Fullness with the band tends to be a very high sensation, like chest discomfort. Spatially, the band is like a golf ball with a small hole in the bottom of it; the GPS is like a banana or narrow tube. I am seeing fewer food intolerances with GPS - there's just more space, but you get full on small amounts of food (powerful weight loss tool). I think GPS is an ideal solution for band patients who have recurrent dilations - it's nice to offer something better than just another band revision. With the band, patients can vomit/regurgitate so much that the pouch gets dilated and this can cause swelling of stomach in the band to the point that it is too tight and must be deflated (typically in the middle of the night for some reason). The GPS doesn't do that which is nice. My opinion is that in some percentage of patients, GPS, like all other weight loss operations, may dilate over time to the point that it isn't as powerful of a weight loss tool as it once was. This is true of all weight loss operations. The good news is that this dilation won't cause an emergency and it would be much simpler to revise than all other operations - simply place additional sutures (plications). GPS patients do describe very significant pain with overeating, especially in the first few weeks after surgery - this is abdominal pain, not chest pain. You would be able to vomit with the GPS - it's just your stomach, only smaller. When we first started, I allowed GPS patients to drink with meals, but we are finding that even with the GPS, it is best to drink liquids between meals or just before a meal, but once you start eating solid food, wait for one hour. This will keep you full longer and full quicker and the weight loss is better. Our weight loss results are just like any other weight loss procedure. We have superstar patients who eat healthy food and burn calories and check in with us weekly and lose weight very successfully. The GPS is just like all other weight loss operations in the sense that it doesn't stop ice cream, chocolate, mushy junk food, etc. These foods are very high in bad calories and fight the weight loss with a vengeance. I think GPS is going to be a big deal as more people learn about it. We are getting more and more calls from around the U.S. and even foreign countries from people interested in plication. I'm also getting more calls from surgeons wanting to learn how to do it. It is a wonderfully simple operation (but still must be done properaly) and one of the lowest risk operations available for weight loss. It is also the least expensive because there is no band or staples or any other medical device. This also allows the incisions (scars) to be tiny (all 5mm incisions). Brad Watkins MD

One interesting thing we have learned about procedures that make the stomach smaller is that cold beverages make things tighter than room temperature or warm liquids. Also, not drinking with meals helps prevent this kind of regurgitation. Ideally, drink liquids before a meal and once you start eating solid food, wait for one hour after to start drinking again. Brad Watkins MD

My recommendations for post-op diet after plication surgery: Week One: liquid foods that don't require chewing such as, applesauce, pureed Soups, Jell-O, pudding, popsicles, anything in a blender or food processor. The idea here is the stomach is healing and there is swelling and we want the stomach to be lazy during the healing period. Weeks Two and Three: soft and mushy foods. Most food is soft and mushy if you take a small bite and chew extremely well and eat slow. The idea here is that you are easing your smaller stomach into foods of thicker consistency. The plicated stomach certainly has swelling after surgery making things tighter for a bit. Post-op swelling varies quite a bit from one patient to the next. Some patients have lots of swelling and they may struggle with liquids until the swelling goes down; other patients have no trouble eating and drinking after surgery. Having difficulty drinking or eating after plication is likely due to swelling that should go down considerably by 2-4 weeks post-op. We certainly don't want to make the plication too tight because this may cause continued difficulty even after the swelling goes down. Many times Pasta is too rubbery especially if microwaved. Much restaurant food is rubbery and better to eat freshly prepared food at home if possible. We've also learned that it is best to drink liquids between meals, stop drinking once you eat solid food and then wait one hour after a meal before drinking. This reduces the chance of the food wanting to come back up and also helps you stay full longer which helps to maximize weight loss. Brad Watkins MD

Since I did not perform JG's surgery I cannot speculate what may have happened. We certainly have not seen this in our plication patients and complications like this should be incredibly rare because there is no stapling or cutting of the intestines involved. I echo the thoughts and prayers sent by the members of this forum that JG have a complete recovery. Brad Watkins MD

I sent a PM to jg62 but I will post some general information here as well. In general, anytime you experience concerning symptoms you should call your surgeon's office. If your surgeon is outside the U.S. and you are unable to reach them, the next step is to go to the nearest emergency room or to call 911. Symptoms of chest pain and dysphagia to liquids (unable to drink liquids), suggests that the plication is too tight and the amount of swelling caused by the surgery is excessive. One way to minimize post-operative dysphagia (aside from the obvious of not making it too tight) is to eradicate the stomach bacteria, Helicobacter pylori, prior to surgery. There are multiple items I have the anesthesiologists give during the surgery to minimize swelling as well. I also perform an endoscopy (stomach scope) at the end of plication procedures to make sure it is not too tight. jg62, I hope you get to feeling better soon. Brad Watkins, MD

Regarding plication after Nissen fundoplication (surgery for severe heartburn/reflux/GERD): My thoughts are that if the Nissen fundoplication is working to control the heartburn, then leave it intact - leave that area alone and then plicate the remaining stomach below that. This way, you have an intact anti-reflux mechanism and an excellent weight loss tool as well. If the previous fundoplication was done through an open surgery (large incision in the middle of your abdomen), then the scar tissue is expected to be greater than if it were done laparoscopically and that would be something to contend with during the surgery. If the fundoplication was done laparoscopically (tiny incisions) then you would expect very little to no scar tissue and therefore this wouldn't add any grief to another operation. When you re-operate on a patient with previous fundoplication, what you find varies quite a bit. Sometimes the wrap (fundoplication) has completely fallen apart and it looks nearly like nothing was done. Sometimes the wrap is very much still present with lots of accompanying scar tissue associated with it. Generally, if the fundoplication is still providing excellent relief from heartburn, chances are good that it is still intact. This correlates very strongly. If the heartburn has returned as bad as ever, chances are good that the wrap is apart. The status of this wrap, which would be easy to evaluate during surgery, might alter a surgeon's opinion on what is best to do surgically during plication surgery. Like so many situations in surgery, great judgment is required to evaluate the endless potential findings and make good decisions about how to proceed. This is an example of evaluating what you are dealing with and making decisions to maximize benefit to the patient while minimizing complications and/or frustration post-operatively. The simple answer is, it would be possible to perform plication after Nissen fundoplication. Surgical findings would dictate how best to proceed regarding takedown the fundoplicatino and plicate the full length vs. leave the fundoplication intact and plicate distal to that. Brad Watkins MD

Repairing hiatal hernias is very important with any weight loss surgery. The presence of a hiatal hernia shouldn't contraindicate surgery, it should just be repaired at the time of surgery. Certainly if a surgeon doesn't repair hiatal hernias then they shouldn't do a weight loss operation. One thing I have learned after doing weight loss surgery for 8+ years now is that ALL patients who have been overweight have a hiatal hernia or at best a weak hiatal area. In my opinion, all patients should have the hiatus explored and stitched to the appropriate size as part of all weight loss operations. Without this, patients have severe reflux (heartburn) after weight loss surgery and it reduces their weight loss success and greatly increases their frustration level. What I have learned is that you have to explore the hiatus, not just glance at it to appreciate how lax the hiatus becomes after being overweight. Overweight is associated with chronically elevated intra-abdominal pressure that continues to dilate the hiatus over time. Too many surgeons ignore this fact during weight loss surgery to the great detriment of the patient. I have fixed many large hiatal hernias (two very large ones this week!) at the time of weight loss surgery (band and plication and band over bypass) and this does wonderful things to how well the patient does after surgery in terms of maximizing their weight loss success and minimizing their frustration. I would say that you could have plication with a large hiatal hernia so long as the hernia is repaired at the time of surgery. We do this every day in our patients. Brad Watkins MD

Hello, Regarding plicated stomach, we've had this for years in the Nissen fundoplication patients without incident. For gastric plication, it is interesting that the stomach looks like a perfect tube on endoscopy (I scope all of my plications in the operating room when we're done) and it looks like a normal tube on upper GI (drinking barium and taking x-rays). Barium doesn't get back in the plicated part of the stomach. That stomach is not going to cause peritonitis because that is caused by intestinal perforation and there is no cutting or stapling of the stomach involved. Basically, the stomach is normal - just folded in on itself. Bacteria wouldn't grow anymore likely than it does now. Typically, if you culture stomach Fluid, it is sterile due to the acid and low pH. (Side note, there is a bacteria called Helicobacter pylori that lives in the stomach lining but that is a separate topic - I always treat patients for H. pylori prior to plication). This plicated stomach will make acid and drain any food or liquid as it does now. Regarding stomach cancer, gastric cancer is quite rare nowadays and you tend to see it in high risk patients such as patients who smoke or consume large amounts of alcohol. Without risk factors, gastric cancer is quite rare. I always perform an endoscopy (stomach scope) prior to plication surgery - I do it in the OR after anesthesia so it's pleasant for patients - so that I know we're not missing anything in the stomach. If a gastric cancer should decide to grow in the plicated areas it would be more difficult to see on a subsequent scope. The folded area does show up on CT scans. At least you still have access to the stomach for endoscopy. For example, in gastric bypass, the stomach is completely inaccessible to any endoscopy so plication at least preserves endoscopic access. There are major differences between "stomach stapling" and plication. Stomach stapling is a lay-term that typically refers to VBG or vertical banded gastroplasty. That was a procedure that stapled a small pouch at the top of the stomach. Plication reduces the entire capacity of the stomach along its length by imbrication and not stapling. VBG was notorious for weight regain later and most surgeons have abandoned this as a result. What little gastric plication data we have, it looks like sleeve gastrectomy data showing in excess of 60% excess weight loss even after two years which is excellent and right up there with the most successful weight loss operations we offer. Also, if operations like gastric bypass dilate over time, this is a big deal. As I'm typing this, the OR nurses are preparing our next patient who is having band over bypass surgery. This is an involved laparoscopic surgery requiring a lot of take down of scar tissue. If a plication dilates years later, you could simply place additional sutures or you could band the plicated sleeve or for that matter you could do any operation because the stomach is still normal and intact. Plication is still considered experimental because we don't have any long-term data in the U.S. but it is such a wonderfully simple operation I do not anticipate any major surprises with it down the road. I really like the plication, I have patients losing weight really well with it and I think it will be a big deal as more people find out about it. I also see the insurance companies really liking the operation since it is inexpensive to perform (no expensive staples or medical devices). When I first started doing band surgery when it was FDA approved in the U.S., no insurance companies covered the band. We published our experience in the surgery journals and this data led to insurance coverage of the band eventually. We will publish our plication results as well and at some point you will see insurance coverage, but that is a ways off at this point. Insurance companies love data. I do too and I love helping people lose weight. Brad Watkins MD

Excellent question. The stomach will always be viable after plication. Since it is just folded in on itself and there is no cutting or stapling, there really is no issue with its viability. Reversing it would involve cutting the stitches and the subsequent bit of scar tissue around the stitches and you would be left with your normal stomach. We know this can be taken down even after many years because we've been doing this for many years when we take down plicated stomach after Nissen fundoplication (a stomach plication operation for severe reflux - heartburn) or after Lap Band surgery (the stomach is plicated over the band). Barretts esophagus, for anyone who hasn't heard about it, is when the esophageal lining changes due to chronic reflux (heartburn, GERD). The esopagus (swallowing tube) is made to handle neutral pH Fluid such as spit and mucous and food. It really doesn't want to see gastric acid or bile. In the case of bad heartburn, the lower esophagus gets exposed to so much acid and bile that it gets irritated and chronically inflammed and has to change its cells to protect itself. These cells look more like stomach lining cells than esophageal lining cells and this is what they call Barrett's esophagus. Dr. Barrett is the physician who discovered this interesting protective mechanism by morphology in the wonderfully designed human body. The problem with Barrett's is that it can form pre-cancerous cells over time and these can progress to cancer. This is why it is a good idea to have an endoscopy (stomach scope, EGD - esophagogastroduodenoscopy) if you suffer from severe heartburn to rule out Barrett's. If biopsies show Barrett's with low grade dysplasia (pre-cancerous change) you need to have more frequent endoscopy to monitor for progression. If you have high grade dysplasia or frank cancer cells this is when esophageal resection (cut the affected area out) is recommended. Moderate grade dysplasia is either more closely watched with frequent endoscopy or treated surgically. The good news is that if the heartburn is treated surgically, in some cases the Barrett's will resolve (go away, cured). I have seen this many times in my own practice. Treatment typically involves addressing the associated hiatal hernia. Hiatal hernia is when the hiatus - the opening in the diaphragm (breathing muscle) - is too large and there is no "valve" to prevent acid and bile from backing up into the esophagus. With that operation, the esophagus is mobilized to ensure that an intra-abdominal portion of the esophagus is below the diaphgram. This is what we call an intact anti-reflux mechanism. After doing laparoscopic weight loss surgery for 8+ years, I have learned that essentially 100% of patients have a hiatal hernia or at best a weak hiatus that needs repair. This is easy to do because it simply involves mobilizing the esophagus to achieve an intra-abdominal portion and stitching the hiatus until it is the appropriate size. This is very important to do in any stomach-reduction surgery because if you give a patient a smaller stomach without an intact anti-reflux mechanism, this creates more severe heartburn and frustrated patients and less successful weight loss. I feel very strongly about creating an intact anti-reflux mechanism with each weight loss operation and I know this is important from personal experience. Many surgeons don't do this - they don't believe in it - to the detriment of their patients. All of this to say, by fixing your hiatus, you may very well achieve resolution of your Barrett's esophagus. Even if the worse should happen and it progresses, you could still have an esophageal resection with gastric reconnection to re-establish continuity with no problem even after plication. Brad Watkins MD

Ghrelin is reduced by pressure on the gastric wall. You do not have to remove stomach to reduce ghrelin. Ghrelin is a feedback hormone meaning when the gastric wall is stretched, ghrelin levels are reduced. The reason ghrelin levels are lower in sleeve gastrectomy patients is due to the smaller size stomach, not from removing stomach tissue. The sleeve that remains still produces ghrelin and levels are reduced by pressure. In gastric bypass, for example, ghrelin levels go to very low levels and the entire stomach is still there. All of the ghrelin producing tissue is still there but the levels are very low due to pressure. No ghrelin level studies have been done in plication, but plication patients describe the same appetite reduction as sleeve gastrectomy patients. There is certainly more data about sleeve gastrectomy, but the plication patients lose weight in the same manner and describe the same appetite reduction. Another important thing to remember about ghrelin is that it is a small part of a very complex appetite mechanism that we understand very poorly and superficially. The only reason ghrelin gets so much press is that the molecular structure of the hormone is know - it has been discovered. We know there are a lot of things floating around in the blood stream that affect appetite that haven't been discovered. All of these hormones are reduced by pressure in the stomach wall, not by resecting stomach tissue. Whereas we don't currently have morbidity and mortality data on the plication, it will be less than sleeve gastrectomy because there is no cutting and no stapling involved. Regardless of the fact that the sleeve gastrectomy has been around longer, many patients do not want to have their stomachs cut and stapled and most of it discarded. The minimal invasiveness of the plication is really resonating with lots of people. Our experience with the plication is that patients are losing weight like the sleeve gastrectomy patients and they are losing weight like the European patients that have had plication. Plication x-rays (barium study) look just like the sleeve gastrectomy x-rays. It creates the same space and works the same way - by pressure with fewer calories. Also, in terms of stomach being folded on itself, we have been doing this for many years with an operation called Nissen fundoplication, an operation done for severe reflux. It is comforting to know that through all of the many years fundoplication has been done, there hasn't been one documented case of a problem with stomach being folded on itself. Though the plication hasn't been around very long, folded stomach has been around a very long time without any issue so we don't anticipate any issue with plication as a weight loss operation. The important truth to keep in mind is that ghrelin levels are reduced by pressure, not by resecting portions of the stomach. Any remaining stomach will produce ghrelin and those levels will respond to pressure, not volume of stomach tissue remaining in the body. Another example is that the Lap Band will reduce ghrelin levels and 100% of the stomach remains. The levels are reduced because the stomach pouch above the band is much smaller and stretching that small portion of gastric wall above the band is creating the reduction in ghrelin levels. Brad Watkins MD

Our website is www.CincyWeightLoss.com. You could call our office for details. Acid reflux will resolve after plication surgery if the associated hiatal hernia is taken care of at the time of surgery. I routinely repair the hiatus at the time of surgery and I think this is important. Feel free to e-mail me with any questions you may have. My private e-mail is Brad.Watkins@CincyWeightLoss.com. Brad Watkins MD

Silk sutures would be a good choice. I prefer 2-O Ethibond suture which is a third generation silk suture. A 32 bougie would be a standard size bougie that is a good choice in my opinion. The surgery would not inflame gallstones. Gallstones are more common in women especially with weight gain and weight loss. That is why gallstones are common in weight loss patients. Brad Watkins MD

Yes, you could have gallbladder surgery now and be ready for another surgery in November or you could have them done at the same time. We have done simultaneous gallbladder surgery with the band and I wouldn't hesitate to do this with a plication as well. Brad Watkins MD

Generally, if you have known gallstones, I recommend removing the gallbladder at the time of weight loss surgery simply because I've seen too many patients with nasty problems from gallstones. If I had gallstones or someone in my family had gallstones I would tell them to get the gallbladder out as soon as practical. Gallbladder surgery pales in comparison to the grief gallstones can cause. Patients with gallbladder attacks seem to develop the massive profanity syndrome. That said, many surgeons make the case for not doing gallbladder surgery unless the stones are bothering you. The problem is that they can bother you in a very unpleasant way and they generally don't check with your schedule first and this generally happens in the middle of the night on a holiday weekend. It's like a ticking bomb... Also, I've seen many examples where gallstones weren't symptomatic until patients started losing weight and they end up having urgent gallbladder surgery on an inflammed organ instead of the smooth, elective, outpatient variety that is so much easier from which to recover. You could go 30 years and not be troubled with gallstones or you could have a massive attack prior to finishing reading this wordy post. Both are possible and the gallbladder decides the timing. Brad Watkins MD

To say that one should choose different operations for different BMI ranges is an often propagated myth by surgeons. The truth is that all weight loss operations are tools for weight loss and regardless of the operation, patients that take full advantage of the tool do great but some patients don't lose that much weight with any operation. Interestingly, if you look at band vs bypass, the bypass looks better the first year, but 5-10 years later the band looks better because bypass weight loss is somewhat "false" in the beginning because it is a disease weight loss with muscle wasting (NOT the way to lose weight in a healthy manner even though it makes the scale look better, temporarily). The problem with bypass is that patients regain weight later requiring revisions. We do a lot of band-over-bypass surgery to create an adjustable bypass so patients can lose weight again. The plication success rate should be no different from other weight loss operations. I anticipate most patients will do very well with the tool but some patients will lose very little weight just like we see with other weight loss operations. I've got a couple of GPS patients (Gastric Plication Surgery is what we call it) who have already lost over 40 pounds in a couple of months - amazing. Obviously, it is early in the game but it is so simple I do not anticipate any massive surprises with the operation. In Europe, plication patients' average weight loss looks better than the band. A common theme of patients not losing weight as fast is eating too much ice cream and/or too many "concentrated sweets" (cake, Cookies, etc). The good news is that when the appetite is turned down after surgery, patients find it much easier to avoid these foods because they are not hungry. I've had a lot of patients -before surgery- tell me, "Well, Doctor, if I could make good food choices I wouldn't need surgery," but then they are pleasantly surprised after surgery at how much easier it is with the appetite turned down and getting full on small meals. Also, sometimes complex emotional eating issues are thrown in there which sometimes requires experts in that area if it is interfering with weight loss but it is rare that patients need that level of help after surgery in my experience. At any rate, we have done band surgery on patients through all BMI ranges and they all lose weight very well when they use the tool effectively. I feel no different about the GPS (plication). I like the plication because there is no malabsorption, no cutting, no rearranging, no foreign body, no port, etc. Plication has a lot going for it. Brad Watkins MD

Gastric plication is done laparoscopically (tiny incisions in the abdomen). POSE (Primary Obesity Surgery Endoscopic) is done by passing a scope down the esophagus (swallowing tube) and placing anchors in the stomach lining. Currently, POSE is a new technology and has not acheived reliable success yet. USGI (POSE company) has a lot of great people working for them and they continue to make positive changes and it may become an ideal solution in the future as they continue to enhance the technology. Brad Watkins MD

We have removed bands and done plication at the same operation with no problem. I do not think that you have to do them as a separate operation or to wait. I think they can be done at the same operation with no problem. Brad Watkins MD

Normal gastric tissue is actually very strong stuff and takes stitches well. We have been using the exact same stitches in the exact same way for other gastric surgeries for years and I can tell you that these stitches, when properly placed, can last forever. I don't worry about "stitches coming loose". I do think that a small percentage of plication cases will have dilation (stretching) over time that may require more stitches to cinch it back up or another operation at the patient's choice. Brad Watkins MD

Plication should have an incredibly low risk for leaks (near zero) since you aren't cutting or stapling anything. The thing about human medicine is that nothing is ever 0% or 100%. There is always a low risk for everything. A rare possibility is that if stomach stitches are placed in an area of chronic inflammation such as the case in patients with previous gastric surgery, there is a small risk the stitches could pull through and create a leak. I have never seen this when stitches are placed on healthy gastric tissue that has never seen surgery before. Regarding nursing a baby after surgery, typically, the main concern is that if you are taking pain medications, the narcotic will be in your breast milk in small concentrations that could affect your baby. Best to consult with your OB physician as they are the experts on breast feeding after surgery. Brad Watkins MD

The simple answer is that, yes, the plication may stretch over time. The stitches (assuming the proper sutures are used) should hold forever (and beyond). The good news is that the majority of patients who have weight loss operations reach their goal weight and do not regain in the long-term. All stomach operations that have ever been developed to assist with weight loss can experience dilation ("stretching"). For gastric bypass, the connection between the small stomach pouch and the small intestine can dilate. For gastric band surgery, the small pouch above the band can dilate. The nice thing about plication is that if a patient has dilation years down the road, you can simply place additional sutures - that would be a simple, short laparoscopic surgery. Also, since the stomach is still there, you could have any other weight loss operation, no bridges have been burned. The best ways to prevent dilation (stretching) in any weight loss operation is to avoid carbonated beverages. There is so much pressure in carbonated beverages, it's like putting an air compressor in your stomach. (Have you ever opened a dropped can of Diet Coke? watch out!) Also, you want to avoid the chronic habit of eating to the point of regurgitation. Over the long-term, this can and does dilate any weight loss operation. I saw a report where a surgeon used Prolene suture for a plication and it came apart so I think that this suture should not be used for plication for sure. Certainly, proper surgical technique is important to the success of any operation and far too often "cheap surgery" does not equate to proper surgical technique. Brad Watkins MD

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