Dr. Watkins,

What is your opinion on the viability of the stomach after the plication surgery. I was informed that eventually the stomach would adhere to itself and really could not be taken down after a month or two. I ask this as a Barretts esophagus patient that would need the use of my stomach should my Barretts progress to esophageal cancer.

Dr. Watkins,

What is your opinion on the viability of the stomach after the plication surgery. I was informed that eventually the stomach would adhere to itself and really could not be taken down after a month or two. I ask this as a Barretts esophagus patient that would need the use of my stomach should my Barretts progress to esophageal cancer.

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

Dear Dr. Watkins:

Thanks for the clear and informative post on the viability of the stomach post GPS. I am sure to be aFUTURE patient, as I have read enough now that I am letting my insurance approval for the lap band go unused and saving money for the surgery.

As I prepare, by educating myself, three burning questions have come to mind about long-term GPS which are somewhat related to this post, and others may also be interested to know:

1. If my stomach is folded in on itself indefinitely, is there any chance of the folded up part growing bacteria, or getting an infection or peritinitis from being all folded up??? Say... could food get stuck in those folded up parts and fester??? I read this somewhere, and hope its not true.

2. If my stomach is folded up indefinitely, what if I ever needed to find out if I had cancer... would an MRI be able to "see through" the folds??? Hope this never happens, but it did cross my mind.

3. Some woman on the Lap Band site claims that GPS is the a "modern version of stomach stapling," and that after time, there will be leaks and cracks and horrible consequences as we get older.

While I realize this surgery is still experimental, wasn't it done in Greece for a number of years? Has that terrible result actually happened to anybody??? And... why arent' more doctors doing this? It is so cool.

Thank you kindly, I am so glad they put up this site as information is hard to find.

Dear Dr. Watkins:

Thanks for the clear and informative post on the viability of the stomach post GPS. I am sure to be aFUTURE patient, as I have read enough now that I am letting my insurance approval for the lap band go unused and saving money for the surgery.

As I prepare, by educating myself, three burning questions have come to mind about long-term GPS which are somewhat related to this post, and others may also be interested to know:

1. If my stomach is folded in on itself indefinitely, is there any chance of the folded up part growing bacteria, or getting an infection or peritinitis from being all folded up??? Say... could food get stuck in those folded up parts and fester??? I read this somewhere, and hope its not true.

2. If my stomach is folded up indefinitely, what if I ever needed to find out if I had cancer... would an MRI be able to "see through" the folds??? Hope this never happens, but it did cross my mind.

3. Some woman on the Lap Band site claims that GPS is the a "modern version of stomach stapling," and that after time, there will be leaks and cracks and horrible consequences as we get older.

While I realize this surgery is still experimental, wasn't it done in Greece for a number of years? Has that terrible result actually happened to anybody??? And... why arent' more doctors doing this? It is so cool.

Thank you kindly, I am so glad they put up this site as information is hard to find.

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

Dr. Watkins: Thank you for your very clear and thorough answer. You are a very rare, and caring, doctor to actually spend time explaining things to people in an online chat room, I am very impressed with this generosity, as you have answered all my questions and I am totally ready to get all my arrangements done and make my GPS appointment at your clinic!!!

Dr. Watkins: Thank you for your very clear and thorough answer. You are a very rare, and caring, doctor to actually spend time explaining things to people in an online chat room, I am very impressed with this generosity, as you have answered all my questions and I am totally ready to get all my arrangements done and make my GPS appointment at your clinic!!!

Rain, you won't be disappointed. He's a wonderful doctor.