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.

great, typical for this information to become available 3 days after my plication.

I knew there were risks, as with any surgery, but "several reports of perforation." That is scary. I am having very little pain, but I am still scared now.

Yeah, me too! 6 days post op! Feeling o.k., though. I sure hope it's just in the first few days and not a risk down the road!

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.

Well, it's a known to other bariatric surgeons and it does not just happen within a few days of surgery.

http://www.obesityhelp.com/forums/vsg/4308190/Unexpected-Complication-from-Vertical-Sleeve-Plication/

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.

Dr. Watkins, do you plan to continue to recommend the Plication procedure in light of this information? My Plication surgery is scheduled for 3/21 with Dr. John Oldham. This makes me very nervous about going through with it.

Amy

Dr Warkins - thank you so much for posting this info. You are a true professional for presenting possible complications as well as the benefits. If gastric necrosis occurs, what options does the patient have?

Thanks again!

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.

I have spoken with several doctors on this issue and all of them decline to do this procedure for this very reason. They believe this is a 'forever' potential complication. As the stomach tissue can slide through the sutures and create a situation where blood flow to the stomach is compromised. John Husted is one of four or five surgeons in the US that is able to take down bypass and revise to DS in the same surgery via lap. I asked him, if you had a patient that insisted on plication and if he wouldn't do it, they would go to another doctor, would he do it? He said no, he would not. They would have to go to another surgeon. He believes this is a dangerous procedure and refuses to do it. He is one of the seriously true revision surgeons in the US.

Most bariatric surgeons decline to do this procedure for this very reason.

This is not a newly known complication, this is something that has been known since the beginning of plication.

As another poster writes, you can't write complication without writing plication.

Dr Watkins, I had my GPS done about 7 months ago by Dr Corvala... I am doing fine, weighing in at about 135 from about 190... But I worry now thinking that a perforation will be inevitable - is there anything that I should do to put my mind at ease?

Thanks!

I had plication combined with the lap band at the beginning of January. I know the plication is new and experimental. And it in combination with the band is still quite rare. I did my research and chose a surgeon who is highly experienced in all of the proceedures. He has studied and done plication for quite a while. My first choice was the sleeve but my insurance would not cover it. So this was my plan B. So far I've had no complications and I hope I don't in the future. I believe finding the right surgeon is key. Do the research before going under the knife. And, if there are complications, make sure you choose a surgeon who can resolve them.

I have to applaud Dr. Watkins for bringing this complication to the forefront, and I hope that they find out what is causing this complication. I realize it seemed like a good option, but my concerns about perforations, and the "what if" always lingered when plication hit the scene especially since it was being marketed as the "sleeve killer" or "super sleeve". Complications are possible with any of the surgeries. I realize this, I had a leak as a revision patient so I am a statistic as well, but I knew going in that the band had done it's damage. I knew my risks for a leak had quadrupled since I had a band first. My heart truly goes out to those that have experienced any complications regardless of surgery type.

Thank you again Dr. Watkins. I appreciate your honesty, and openness on your opinion on GPS at this time.

gastrectomy.

If you currently have a plication consult or surgery scheduled I would recommend that you discuss this with your surgeon.

I faxed both postings from Dr. Watkins to my surgeon, and he is supposed to call me back and discuss.

Thanks,

Amy

Dr Watkins,

It speaks volumes for your character that you bring your findings to this board. Thank you for updating us.

I believe there is a member on here that experienced this, i remember reading and being shocked that she was pretty far post op. Like 6 months i think. Maybe she and others will post again because it's important for people to know.

Well,

First of all, i am kind of suspect of a doctor or a patient facilitator posting on this board, made for surgery patients. i tend to think that a doctor posting on this board is pretty much looking for cheap advertising. Sorry to be so frank. Scaring patients just on YOUR LIMITED EXPERIENCE ?

i think Dr. Watkins is misinformed due to the little information he has availabale to him. if he hasnt done enough plications, maybe hes not doing it right. Where did you learn your plication techique from Dr, Watkins ?

i think lapband patients are having trouble at a higher percentage, and gastric sleeve patients with leaks have also a higher percentage of failure.

You say nobody can know what will happen 10 years from now ? YES YOU CAN. Heres one of several links.Here´s one going back 10 years exactly.

http://www.laparosco...ONS_ABOUT_TVGP/ and go to the MMESA Dr Talebpour morbid obesity gastric plication report of 500 cases

heres another study of 135 patients. check the stats

.

http://www.ncbi.nlm....pubmed/19081482

heres some more info:

LAPAROSCOPIC TOTAL GASTRIC PLICATION. 2- YEAR RESULTS AND COMPARISON TO SLEEVE GASTRECTOMY.

George Skrekas MD, ISS, EAES, General surgeon, Specialist in advanced laparoscopy & bariatric surgery

PURPOSE: The presentation of our results with total gastric plication (imbrication) in a 135 patients series and comparison to a randomized series of 80 patients who underwent sleeve gastrectomy in the same period.

METHODS: The study was designed as prospective - double. The GROUP I is consisted from 135 patients (104 women and 31 men) who voluntarily underwent gastric plication in a 2-year period (2008-2010). The GROUP II includes 80 randomly selected patients (50 women and 30 men) who underwent sleeve gastrectomy in the same period. The two groups were comparable as to age (36 vs 35.4 years) but differed as to the initial BMI (BMIGroupI = 39.5 vs BMIGroupII= 46.5Kg/m2).

RESULTS: 12 patients of GROUP I (8.8%) presented post operative complications of which 4 cases were treated surgically ( 1 case of gastric prolapse, 1 case of Portal vein thrombosis with partial jejunum necrosis and 2 cases of late gastric occlusion due to the formation of intragastric seroma). In the last 2 cases we did reversion of the plication 3 months after the primary operation. The mean follow-up was 20.4 months (13-32). In the group of gastric plication (GROUP I) the mean (%) excess weight loss (EWL) was 65.3%. Weight loss was significantly greater in patients with initial BMI < 45 (69.9% vs 55.5%, p = 0.006). 29 patients of GROUP I (21.4%) had poor weight loss (EWL <50%), while in 8 of them (5.9%) the surgery was deemed as failure (EWL <30%). Patients with an initial BMI> 45 were twice as likely to fail loosing adequate weight than those who had BMI <45 (36% vs 18.1%). The patients who underwent sleeve gastrectomy (GROUP II) achieved significantly greater weight loss (EWL = 81.7% vs 65.3%, p <0.001) while they had 9 times less probability of insufficient weight loss (2.5 vs 21.4%). The overall weight loss was considered satisfactory in 78.6% of the patients who underwent gastric plication and in 97.5% of those who underwent sleeve.

CONCLUSION: The total gastric plication surgery presents some good features: adequate gastric restriction without implants or gastrectomy, simplicity, reversibility and acceptable risk of complications. In the short-term, the total gastric plication is able to provide an acceptable weight loss in about 80% of patients, but is considerably less effective when compared to sleeve gastrectomy. According to our experience, the total gastric plication might be offered as an option for the treatment of "less heavy" bariatric cases with BMI <45 because beyond this limit, the probability of insufficient weight loss or failure is high (36%).

ALL SURGICAL SOLUTIONS TO WEIGHT LOSS HAVE RISKS, MY COUSIN ALMOST DIED, 2 WEEKS IN ICU FOR A LEAKING

GASTRIC SLEEVE, IT WASNT DETECTED AFTER 2 BARIUM TESTS. AND BY MY OWN EXPERIENCE WITH WEIGHT LOSS SURGERY, NOTHING IS MORE DANGEROUS THAN REMAINING FAT !!

SO TO ANYBODY CONSIDERING WEIGHT LOSS SURGERY, PLEASE DO YOUR HOMEWORK, BUT DON´T BASE YOUR DESICION ON DR WATKINS OPINIONS OR RECOMMENDATIONS, UNLESS HE HAS A STUDY BEHIND HIM,SEEMS KIND OF UNPROFESSIONAL OF HIM TO BE POSTING HERE, DO REAL DOCTORS HAVE THE TIME TO POST ?

...

SINCERELY

BORDER GUY...

Dr. Watkins

How old are you ?

Where did you learn your gastric plication techique ?

From whom ?

How many did you see being performed ?

How many did you perform under supervision ?

How many have you done alone ?

How many complications have you had ?

Please let us know who were those "several" doctors you "spoke too" ?

Ive contacted 6 doctors in the Baja area in the last 24 hours, and showed them your post. ALL OF THEM, ALL OF THEM, think your opinions are nothing more than that, Opinions NOT based on experience or fact.

I spoke with Dr. Lopez Corvala, Dr. Kuri, Dr. Aceves, Dr Huacuz, Dr. Abril and Dr. Ham.

NONE OF THEM KNOW WHERE YOU TRAINED, And they all think your just trying to pull patients your way...

i welcome your response, you´ve got so much time on your hands, you should be able to respond soon...

border guy

Well,

First of all, i am kind of suspect of a doctor or a patient facilitator posting on this board, made for surgery patients. i tend to think that a doctor posting on this board is pretty much looking for cheap advertising.

I think it is a given it is free advertising. Why else would an MD surgeon post on message boards?

Sorry to be so frank. Scaring patients just on YOUR LIMITED EXPERIENCE ?

With all due respect, 99.9% of plication surgeons have limited experience.

i think Dr. Watkins is misinformed due to the little information he has availabale to him.

He is and he isn't. This is an easy surgery to perform, a monkey could do it. Most surgeons won't do it because this is a KNOWN complication of THIS surgery type. Dr. Watkins is just now finding out about it. THAT is what is spooky.

if he hasnt done enough plications, maybe hes not doing it right. Where did you learn your plication techique from Dr, Watkins ?

Again.... this is a known complication of this surgery type. ALL surgery types have known complications, this is one for plication.

i think lapband patients are having trouble at a higher percentage, and gastric sleeve patients with leaks have also a higher percentage of failure.

A leak is not a surgery failure unless the person dies, most do not. A failure does not mean someone had complications. I take it you are defending YOUR surgery type by burying your head in the sand? This is a known complication of the surgery, deal with it. Sleeves are THE safest surgery long term. Sorry to inform you of facts.

You say nobody can know what will happen 10 years from now ? YES YOU CAN. Heres one of several links.Here´s one going back 10 years exactly.

SO TO ANYBODY CONSIDERING WEIGHT LOSS SURGERY, PLEASE DO YOUR HOMEWORK, BUT DON´T BASE YOUR DESICION ON DR WATKINS OPINIONS OR RECOMMENDATIONS, UNLESS HE HAS A STUDY BEHIND HIM,SEEMS KIND OF UNPROFESSIONAL OF HIM TO BE POSTING HERE, DO REAL DOCTORS HAVE THE TIME TO POST ?

Right, damn sure don't base it on your ramblings or Watkins.