I'd like to share my experience after 2 weeks of gastric plication

[NotSoLittleMermaid 14]

Thank you so much. Yes he is very caring and attentive.

[ouroborous 519]

Anyone seen ANY research yet on the M&M (morbidity and mortality) numbers for plication? Also, I'd be interested in seeing EWL (excess weight loss) figures.

I would be stunned if plication can approach the sleeve for EWL, since the ghrelin is still present (although it may not be as prevalent without fundus stretching; then again, the plication may also trigger essentially permanent ghrelin secretion; who knows?) and the ghrelin reduction of VSG is posited to be one of the primary mechanisms for EWL from VSG aside from the purely restrictive aspects. I'm sure that initial weight loss in plication is good, but then again it's also good in all WLS -- banding, DS, and so on. It's the long term maintenance that I'm concerned about; that's what drew me to VSG over, say, lap-band (aside from the foreign body issues): VSG has, hands-down, the best 5 year EWL maintenance statistics around. Very interested to see how plication will stack up, but I know that that data is simply not available. Calling plication a "super sleeve" without this kind of data seems to me to be at best misleading, and at worst downright deceptive. But, time will tell; hopefully all the plication patients thrive and do well.

The only place I can see plication touching VSG is on the M&M figures, since there's no resection. But even that is hypothetical, as there are a lot of unanswered questions (what are the effects of all that "bundled" tissue long term? can the staples come undone? are there vascularization effects? &c &c)

Edited September 8, 2010 by ouroborous

[JoanieW 13]

Anyone seen ANY research yet on the M&M (morbidity and mortality) numbers for plication? Also, I'd be interested in seeing EWL (excess weight loss) figures.

I would be stunned if plication can approach the sleeve for EWL, since the ghrelin is still present (although it may not be as prevalent without fundus stretching; then again, the plication may also trigger essentially permanent ghrelin secretion; who knows?) and the ghrelin reduction of VSG is posited to be one of the primary mechanisms for EWL from VSG aside from the purely restrictive aspects. I'm sure that initial weight loss in plication is good, but then again it's also good in all WLS -- banding, DS, and so on. It's the long term maintenance that I'm concerned about; that's what drew me to VSG over, say, lap-band (aside from the foreign body issues): VSG has, hands-down, the best 5 year EWL maintenance statistics around. Very interested to see how plication will stack up, but I know that that data is simply not available. Calling plication a "super sleeve" without this kind of data seems to me to be at best misleading, and at worst downright deceptive. But, time will tell; hopefully all the plication patients thrive and do well.

The only place I can see plication touching VSG is on the M&M figures, since there's no resection. But even that is hypothetical, as there are a lot of unanswered questions (what are the effects of all that "bundled" tissue long term? can the staples come undone? are there vascularization effects? &c &c)

There have been some studies done on the GPS. One of them was for about three years, and you can find it at bariatrictimes.com. From that study, the EWL was comparable to VSG. There was another two-year study in Brazil. But you're right. We don't have enough data. I just knew that I couldn't do the VSG but I had to do something. This was a viable alternative for me. I had my surgery on Aug. 6, and I am down 21 pounds since my one week postop diet. I do get hungry, but not like I used to. It's not that all consuming hunger I used to get where I couldn't stop eating. I eat a very small amount, and I'm satisfied. I think your question about what happens to the bundled long term tissue is a good one and is a concern of mine. Since Dr. Watkins posts here from time to time, I hope he sees this and will give us his opinion. At the end, I have posted a copy of what Dr. Brad Watkins has had to say about the surgery. By the way, there are no staples, just sutures.

#12 (permalink)

07-14-2010, 02:53 PM

DrWatkins

Registered User

Join Date: Jun 2010

Posts: 25

Gender: Male

City: Cincinnati

State: OH

Re: Calling all (TGVP) people!!! new procedure

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

[DrWatkins 13]

Anyone seen ANY research yet on the M&M (morbidity and mortality) numbers for plication? Also, I'd be interested in seeing EWL (excess weight loss) figures.

I would be stunned if plication can approach the sleeve for EWL, since the ghrelin is still present (although it may not be as prevalent without fundus stretching; then again, the plication may also trigger essentially permanent ghrelin secretion; who knows?) and the ghrelin reduction of VSG is posited to be one of the primary mechanisms for EWL from VSG aside from the purely restrictive aspects. I'm sure that initial weight loss in plication is good, but then again it's also good in all WLS -- banding, DS, and so on. It's the long term maintenance that I'm concerned about; that's what drew me to VSG over, say, lap-band (aside from the foreign body issues): VSG has, hands-down, the best 5 year EWL maintenance statistics around. Very interested to see how plication will stack up, but I know that that data is simply not available. Calling plication a "super sleeve" without this kind of data seems to me to be at best misleading, and at worst downright deceptive. But, time will tell; hopefully all the plication patients thrive and do well.

The only place I can see plication touching VSG is on the M&M figures, since there's no resection. But even that is hypothetical, as there are a lot of unanswered questions (what are the effects of all that "bundled" tissue long term? can the staples come undone? are there vascularization effects? &c &c)

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

[NotSoLittleMermaid 14]

Great and informative post! Makes me feel even better about my decision. :001_tongue:

[JoanieW 13]

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

Thank you, Dr. Watkins. I knew you would come through for us. I feel a lot better about my decision!