DrWatkins

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

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

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

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.

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.

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.

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.

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.

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

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

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