DrPleatman

As a surgeon who takes care of many self-pay patients, I will tell you that I also fear complications. It is bad enough when one of my patients has a complication, but it is worse when that complication may bankrupt them. Fortunately complications are rare, so it isn't often a problem. It is also fortunate that many insurance companies that don't cover WLS will cover the cost of complications. BLIS is also a reasonable program, though I will admit that I don't use it because it is expensive and they require you to use them for ALL patients... it will raise the cost of the operation by more than $1000. Ultimately it's just another factor you have to consider when deciding to have bariatric surgery. Do your research and find a surgeon you feel comfortable with.

I think it is open to anyone, though I think if you just say, "Please cover VSG because I want it" your vote may not count for much. On the other hand, it may not hurt to try. Mark Pleatman MD drpleatman.com

Here's your chance to petition Medicare to cover the sleeve gastrectomy. Following is text from a letter I just received from ASMBS: Mark Pleatman MD Dear ASMBS Member, As you are aware, the Centers for Medicare & Medicaid Services (CMS) has opened a public discussion and comment period regarding a National Coverage Determination (NCD) for the Vertical Sleeve Gastrectomy. Comments are open UNTIL October 30, 2011 so please access the CMS NCD comment page TODAY and support Medicare coverage for sleeve gastrectomy. To assist you in this effort, below we have provided a direct link to CMS and sample language that you can personalize in submitting your comments. Please be sure to focus on the scientific attributes of sleeve gastrectomy and the fact that many private health plans now routinely provide coverage for this procedure. Please avoid any inflammatory language and be aware that our time is now to get CMS coverage for the vertical sleeve gastrectomy. We appreciate your support. Sincerely, Robin Blackstone, MD, FASMBS ASMBS President Jaime Ponce, MD, FASMBS ASMBS President Elect Ninh Ngyuen, MD, FASMBS ASMBS Secretary Treasurer John Morton, MD, FASMBS Chair, ASMBS Access to Care Committee LINK TO CMS COMMENT PAGE: https://www.cms.gov/medicare-coverage-database/details/submit-public-comment.asp TEMPLATE FOR COMMENTS REGARDING MEDICARE NATIONAL COVERAGE DETERMINATION FOR VERTICAL SLEEVE GASTRECTOMY Dear Dr. Berwick, Thank you for opening a National Coverage Determination for the Vertical Sleeve gastrectomy. As a practicing healthcare professional who treats those affected by morbid obesity, I can attest to the safety and efficacy of this procedure. Data exist to demonstrate that weight loss and complications for the vertical sleeve gastrectomy are comparable and fall between two CMS-approved weight loss surgeries --Roux-en-Y gastric bypass and adjustable gastric banding (NEJM 2009 Wolfe, JAMA 2010 Birkmeyer, Annals of Surgery 2011 Hutter). Furthermore, Medicare coverage of vertical sleeve gastrectomy will afford those Medicare patients affected by obesity an additional treatment option for addressing their weight and obesity-related comorbidities while maintaining gastrointestinal continuity. In fact, there are circumstances where the vertical sleeve gastrectomy was an ideal treatment option for my patient: CITE EXAMPLE Expanding Medicare coverage for vertical sleeve gastrectomy will ensure that Medicare patients have access to the same treatment options that other non-Medicare patients already have. I wholeheartedly urge you to provide coverage for the vertical sleeve gastrectomy. Sincerely,

The bad news is that Medicare still does NOT cover sleeve gastrectomy. The good news is that they are now actively considering it. You have until October 30 to voice your opinion. The Centers for Medicare and Medicaid Services has announced they are considering covering laproscopic sleeve gastrectomy for eligible Medicare beneficiaries when performed in a recognized center of excellence. Since 2001, Medicare has covered laproscopic gastric banding, Roux-en-Y gastric bypass and biliopancreatic diversion with duodenal switch. It is asking for public comments on the effects of the surgery for the Medicare population. The comment period is open until October 30, 2011. A decision is expected by March 30, 2012. Mark Pleatman MD drpleatman.com

I can do bands, bypasses, and sleeves. How is recommending one operation over the other advertising? The information I discussed regarding patient satisfaction came from the Michigan Bariatric Surgery Consortium Study being run by Blue Cross of Michigan, a state where band placement is on the decline. This site's owners would prefer that I not say negative things about bands. If you want a band, get one. Mark Pleatman MD Mark Pleatman MD Weight Loss Surgery Website

Add a teaspoon of ground cumin to the soup at the beginning. When you serve it, put in some fresh lemon juice and garnish with a bit of fresh coriander. If you though it was good before, you will really love it with these additions. I let patients have this fairly early in the post-op course. Mark Pleatman MD Mark Pleatman MD Weight Loss Surgery Website

Good news from United Healthcare. They now cover Vertical Sleeve Gastrectomy the same as they would for any other bariatric operation. This is a milestone, as they are the first insurance company to accept VSG as being an effective "stand-alone" operation for treatment of severe and morbid obesity. Mark Pleatman MD Mark Pleatman MD Weight Loss Surgery Website 248-334-5444

I wasn't calling anybody names or singling out a particular surgeon. The article I posted was not preselected. It was from the latest edition of the Obesity Surgery Journal. I agree that Dr. Cirangle is excellent; he taught me bariatric surgery. Even his leak rate is not zero. One needs to be careful about making judgments about small series; your statement that under 1% is OK and above 1% is not makes no sense, as it would be the same as saying that 2 leaks in 210 patients is acceptable, but 3 is not. The fact is that there is no statistically significant difference between 2 and 3 leaks in a series this size. And then, there are other issues to consider. At the recent VSG Summit Conference it was shown that leak rates are higher when narrow bougies are used, as the pressure in the sleeve is higher (though weight loss is better). I use a very narrow bougie (32 Fr), so one would predict that my leak rate would be higher than if I used a large bougie. You also need to consider how many revisional procedures are being done, as well as the risk factors and comorbidities of the patients. You have to make sure you are comparing apples to apples. Finally, I didn't start this fight. I was responding to the inappropriate comment by Wasabubblebut that I am "kinda cheap for a reason," as well as the downright false statement that my patients are only allowed one night in the hospital. In addition, your administrators are claiming that one needs to have done 250 VSGs before they can be trusted. Please supply data to support this claim. I'm not here to "push myself on anyone in this forum; only to defend myself against false and misleading accusations. Respectfully, Mark Pleatman MD Mark Pleatman MD Weight Loss Surgery Website

I thought I would post a recently published abstract from the Journal "Obesity Surgery," one of the leading Bariatric Surgery Journals. The reason I do this is to point out the difference between real research and the anecdotal "research" reported by some people, consisting of reading of posts on forums such as this and others. This series reports 6 staple line leaks in 200 patients, for a rate of 3%. This is a fairly typical leak rate reported in the literature; my leak rate is slightly lower, but in the same range. If your surgeon says he has done 600 VSGs and never had a leak, he is either a god or a liar. You decide. Mark Pleatman MD www.drpleatman.com G. Casella1, E. Soricelli1, M. Rizzello1, P. Trentino1, F. Fiocca1, A. Fantini1, F. M. Salvatori2 and N. Basso1 (1) Department of Medical and Surgical Digestive Diseases, Policlinico ?Umberto I?, University ?La Sapienza?, Viale del Policlinico, 00161 Rome, Italy (2) Department of Radiological Sciences, Interventional Radiology, Policlinico ?Umberto I?, University ?La Sapienza?, Rome, Italy Received: 22 January 2009 Accepted: 1 April 2009 Published online: 21 April 2009 Abstract Background Laparoscopic sleeve gastrectomy (LSG) is gaining popularity as a ?per se? bariatric procedure due to its effectiveness on weight loss and comorbidity resolution. The most feared and life-threatening complication after LSG is the staple line leak and its management is still a debated issue. Aim of this paper is to analyze the incidence of leak and the treatment solutions adopted in a consecutive series of 200 LSG. Methods From October 2002 to November 2008, 200 patients underwent LSG. Nineteen patients (9.5%) had a body mass index (BMI) of >60 kg/m2. A 48-Fr bougie is used to obtain an 80?120-ml gastric pouch. An oversewing running suture to reinforce the staple line was performed in the last 100 cases. The technique adopted to reinforce the staple line is a running suture taken through and through the complete stomach wall. Results Staple line leaks occurred in six patients (mean BMI 52.5; mean age 41.6 years). Leak presentation was early in three cases (first, second, and third postoperative (PO) day), late in the remaining three cases (11th, 22nd, and 30th PO day). The most common leak location was at the esophagogastric junction (five cases). Mortality was nihil. Nonoperative management (total parenteral nutrition, proton pump inhibitor, and antibiotics) was adopted in all cases. Percutaneous abdominal drainage was placed in five patients. In one case, a small fistula was successfully treated by endoscopic injection of fibrin glue only. Self-expandable covered stent was used in three cases. Complete healing of leaks was obtained in all patients (mean healing time 71 days). Conclusion Nonoperative treatment (percutaneous drainage, endoscopy, stent) is feasible, safe, and effective for staple line leaks in patients undergoing LSG; furthermore, it may avoid more mutilating procedures such as total gastrectomy. Keywords Morbid obesity - Bariatric surgery - Sleeve gastrectomy - Complication - Leak

Yes, it's true that I have had a couple of leaks after VSG. I am honest about admitting them. Whether or not that makes my leak rate higher than that of other surgeons who deny ever having had a leak is questionable. Certain people on this site push their own surgeon. I suppose that is up to them. Certain people on this site badmouth me based on rumors and misinformation. Certain people on this site give out a lot of medical information in spite of the fact that they are not physicians. This is unfortunate. All I can do is give the facts. My patients can stay in the hospital as long as they need to. The hospital has agreed to a certain price, and this price is not changed if patients stay longer. My scrub tech inflates the stomach with air and I check it to make sure the staples fired correctly. If there is any question, I will inflate the "real" stomach in the patient or even do an endoscopy. If there is a question of a leak after the surgery, I will get an upper GI series (using gastrograffin, a Water soluble contrast). Though gastrograffin is more expensive, we use it because it will be absorbed if it leaks out. The bad thing about gastrograffin is that it is very harmful to the lungs if aspirated; in addition, it gives lousy pictures. Barium is safer in the lungs and gives much better pictures; we avoid it if there is suspicion of a leak. So you see it's not just about the money. The only reason my price is low is that there are 3 hospitals bidding for my business. My complication rate is low and my patients do well. They like having me there. Finally, if you have a question about me or anything else, give me a call or shoot me an email. Mark Pleatman MD Member ASMBS Member SAGES, serving on Bariatric Liaison Committee, Ethics Committee, Go-Global Committee, Technology Committee Mark Pleatman MD Weight Loss Surgery Website 248-334-5444 Email info@drpleatman.com

That's too bad. It's generally best to convert to gastric bypass or sleeve gastrectomy at the same time. Now you won't be able to have anything done (if you want insurance to cover it)until you regain all the weight again. Mark Pleatman MD Index 248-334-5444

You will be very happy with the results if you have a gastric bypass. You definitely qualify for it. Sleeve gastrectomy is also a great option for you. Your mother, on the other hand, would be better off getting a duodenal switch. It is unlikely that she will lose more than 200 pounds with gastric bypass. Mark Pleatman MD website www.laparoscopy.com/pleatman

Do plenty of research. Check out the "complications forum." You need to talk to people who have had problems; not just patients who have been successful. You should also definitely check out the sleeve gastrectomy, which is becoming very popular, and may have a better success rate. Mark Pleatman MD website www.laparoscopy.com/pleatman

I appologize if it sounded as if I was criticizing only Mexican surgeons; US surgeons are probably just as guilty. The fact is that I don't generally see band patients from other US surgeons. I agree with you that there are many excellent Mexican surgeons. The surgeon who trained me in LapBand is from Mexico! I've been to his clinic, and have done surgery at his hospital. Finally you ask about leaks. I've had a few. You say your surgeon has done more than 500 sleeve gastrectomies and has never had a leak. If he's telling the truth, that's great. Mark Pleatman MD

It costs $2000 more if your old band is being removed at the same time. The company that makes the LapBand will only pay if you can prove that the band was defective. Slipped or eroded bands wouldn't be covered. Leaking bands generally leak because they were punctured by a needle during implantation. Basically you are out of luck. Taking out a band is a trivial procedure; converting to a sleeve is not. It is a tragedy for the patient to remove the band; that's why I always recommend conversion to sleeve or bypass. By the way, someone asked if business is slow. Happily, it is not. I would just like to get the word out that the band is a dying operation, and will probably go away in the next few years. I am saddened every time I get a call from a patient who just came back from Mexico, asking to have their band adjusted by me. Rarely have they even HEARD OF sleeve gastectomy. Today I was chatting with the company rep from Covidien, who partners with Allergan, makers of LapBand. Even she said that they are predicting that the LapBAND will soon be obsolete! Mark Pleatman MD

I remove bands, though I prefer to convert to something else like sleeve gastrectomy. We charge around $5000 for simple removal. Mark Pleatman MD 248-334-5444 Web Page: laparoscopy.com/pleatman

You should not have problems after removal of the band. If you are, something may be wrong. After the band has been present for a long time, a sheath of scar tissue forms around it. When the band is removed, that scar tissue may remain and act as a pseudo-band, even if the band is removed. I've seen this on several of my patients. You have to remove this scar tissue to allow the stomach to go back to its previous shape. If you are having problems you should have your doctor order an upper GI series to see what your stomach looks like. Mark Pleatman MD Web page: Index

PB is productive belch (Vomiting). Think REAL HARD about getting a band. I haven't put on any bands in a few years, as so many patients are unhappy with them. Of all the weight loss operations, dissatisfaction is HIGHEST with the band (this is from a large study with more than 10,000 patients). Delay your surgery. Find out if you can get a sleeve gastrectomy instead. Mark Pleatman MD Web page: laparoscopy.com/pleatman

Once a bariatric patient, always a bariatric patient. If your band is removed you will regain your weight. I strongly encourage patients to convert to something else if the band has to be removed. I will convert to either RNY or sleeve gastrectomy, though my personal preference is for the sleeve. Besides, most band patients prefer the sleeve for the same reason they didn't want the RNY in the first place. You get great restriction with no rerouting or Vitamin problems. Mark Pleatman MD Web page: laparoscopy.com/pleatman

There isn't anything specific you can do to prevent the slippage (prolapse) from recurring, other than not eat foods that you chew! By the way those barium swallows give you a significant amount of radiation... like 50 mammograms every time you get one. Good luck. Mark Pleatman MD Click for website: Index 248-334-5444

Once the band has slipped, you need an operation. Bands don't "fix" themselves with an unfill. They will reslip once they are refilled. I guess your doctor is tired of messing around with it. Perhaps he is afraid that you will start binge eating if he does an unfill before the operation. You will be so much happier after getting a sleeve gastrectomy anyway. Good luck. Mark Pleatman MD Index

If your band is completely unfilled and you still can barely tolerate liquids, it has probably slipped. The barium swallow x-ray is generally reliable in making the diagnosis. If this is the case, you need an operation. Dr. Ortiz would probably replace/repair the band. My personal preference would be, as I have said before, to remove it and convert to something else. Most band patients don't like the idea of a gastric bypass, so I have been converting to sleeve gastrectomy. I know that this isn't what you want to hear, but that's my honest opinion. If you don't have insurance and have to pay for it yourself, it will cost around $12000. Mark Pleatman MD Index 248-334-5444

Scout: I think you were misinformed about the dangers of "scar tissue" on your liver. The fact is that scar tissue always forms around the LapBand. Since the stomach is right next to the liver, there will always be some scar tissue there. Scar tissue is not the same as liver damage. Relax. You don't have liver damage. Mark Pleatman MD Index

This is a common question. Bariatric operations don't cause you to lose weight; they make you EAT LESS food. If you are at a normal weight and already eat a "normal" amount of food, you won't lose weight. I commonly removed bands for reasons such as slippage or frequent vomiting/band intolerance, and convert to either RNY or VSG. These patients lose a little weight and then just maintain. Of course I would never do a PRIMARY bariatric operation on someone who only had 20 pounds to lose. Mark Pleatman MD Index

Slipped bands suddenly become very tight, with symptoms of acid reflux, nausea, and vomiting. A simple X-ray shows a typical change in orientation of the band. The diagnosis is confirmed with an upper GI series, where you drink some barium liquid as they take x-ray pictures. Mark Pleatman MD Index