DrPleatman

You can be sure that the person who is buying them (as well as the others who bid for them) plan on implanting them. I've got plenty of sample bands lying around my office. There is no reason I would go out and spend $345 on Ebay to get one unless I planned on using it. If I were a prospective patient I would want to know WHO these buyers were, and then make sure everybody knew who they were. A boycott would be the quickest surest way to stop this type of behavior. Another approach would be to contact the FDA. They might be interested in dealing with the problem. Mark Pleatman MD

We have a package price of $12,500 which includes surgery, hospital, anesthesia, and unlimited fills. Further details are on my web site. Mark Pleatman MD www.laparoscopy.com/pleatman Bloomfield Hills, Michigan

It's hard to imagine that Mexican surgeons would be doing something different from what we do in the USA. Remember; the Mexicans were doing it before we were, and Ortiz trained many of us. The Mexicans attend Conventions where results/complications are discussed. Everybody puts in sutures to try to prevent prolapse, and everybody is aware that too many sutures, especially near the buckle, will increase the risk of erosion. This is what O'Brien taught all of us. Mark Pleatman MD

Photonut asked for statistics on band erosion from Australia. O'Brien has the largest series, and his erosion rate is 3%; but he claims to have had no erosions in the last 600 cases. I've added below the abstract from his paper on the subject. Those of you who are interested in poking around the medical literature can go to http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?DB=pubmed and look for yourself! Mark Pleatman MD O'Brien PE, Dixon JB. Monash University Department of Surgery and the Alfred Hospital, Commercial Road, 3181, Melbourne, Victoria, Australia. paul.obrien@med.monash.edu.au Following its introduction in 1993, the LAP-BAND (INAMED Health, Santa Barbara, CA) has been used extensively across the world for the treatment of obesity, and data on safety and effectiveness are now available. This review draws on the literature and our own clinical patient base to provide an overview of the early and late problems associated with LAP-BAND placement and its effects on weight loss. It has proved to be a remarkably safe procedure. A report analyzing international data on laparoscopic adjustable gastric bands identified 3 deaths in 5,827 patients (approximately 1 in 2,000). In our series of 1,120 patients, there have been no deaths and no life-threatening perioperative complications. Significant early complications occurred in 17 (1.5%) of our patients; late problems have been more common, particularly during our early experience. Prolapse of the stomach through the band occurred in 125 (25%) of our first 500 patients but has occurred in only 28 (4.7%) of our last 600 patients. Erosion of the band into the stomach occurred in 34 patients (3%); all occurred in the first 500 patients. No erosions have occurred in the last 600 patients. Both problems are treated laparoscopically by removal and replacement. Combined international data show that weight loss after LAP-BAND placement is characterized by steady progressive weight loss over a 2- to 3-year period, followed by stable weight out to 6 years. This pattern reflects the benefit of adjustability. For the international series, the percent excess weight loss (%EWL) at 2 years has been between 52% and 65%. In our series, %EWL at 5 years and 6 years was 54% and 57%, respectively. The LAP-BAND is proving to be extremely safe, able to facilitate good weight loss, and able to maintain weight loss over time.

Unfortunately you are never "out of the woods" for either erosion or slippage. I've operated on one patient with band erosion 5 years after it was placed in Mexico (not by Dr. Ortiz). By the way, I do endoscopy. I had an additional 1 year of fellowship training in endoscopy. If I 'scoped all my band patients on an annual basis, I could increase my income nicely; but I don't because I don't think it is necessary. I get paid about $200-$250 for an endoscopy; hospital charge is somewhat less than $1000... so I don't know who came up with a price of $4200 for endoscopy in the USA. Mark Pleatman MD

Delarla requests that I appologize to the "entire obese community" for (I think) suggesting that people not to be obsessed about their bands. In the past few days I have received emails from several patients asking if they should have their perfectly functioning bands removed now, before they erode. I now see a post suggesting that all Band patients should have mandatory annual endoscopies. Does this sound like obsession to anyone? I have never intended to offend anybody; I am only trying to offer some useful insights after dealing with many 100s of obese patients. I am indeed sorry if I have offended anybody. If you want further appologies, please email me directly. Many people complain that insurance companies are reluctant to pay for LapBand. I humbly suggest that the best thing we can do to REALLY piss off the insurance companies is to willy-nilly require endoscopy on all our patients every year! Imagine the cost! And for what benefit? Actually not much. In fact, erosion, though devastating in its implication for the band (mandatory removal), is otherwise benign. There are actually patients with eroded bands who don't want them removed, as they are still functioning. So if your band is working, leave it alone and be happy. If you start having problems, there's plenty of time to figure it out. Mark Pleatman MD

I was not being flippant with my comments. If your band has eroded and been removed, you can't just sit there and sulk about it. Of course you are upset. You have had a loss. You are grieving, but self-pity gets you nowhere. My job as a bariatric surgeon is to help my patients lose weight. I have to guide them through the decision-making process. You picked the band because it was the safest simplest operation, with the lowest complication rate. But that complication rate is NOT ZERO. For you it was ONE HUNDRED PERCENT. Now you have another decision to make. Now I have to help you (if you are my patient) decide what to do next. How important is it for you to lose weight? For some, they may believe that the risk of another operation is too high. Others re-start the thought process and decide that perhaps they are willing to have another operation, even though originally they would not have agreed to have the bypass. Remember, the great thing about the Band is that you don't burn any bridges with it. If it doesn't work, you can try something else. For those afraid of the bypass, sleeve gastrectomy is a reasonable option. Nothing is bypassed, there are no Vitamin issues, and there is no rerouting. There's no dumping. In addition, there are still other options later, if you don't lose enough weight. Trish... what don't I get? It's not like you're all moslems and I am asking you to accept Jesus. Is this some kind of religion here where "Once a bandster, always a bandster"? Finally, I WOULD send a family member to Dr. Ortiz. Mark Pleatman MD www.laparoscopy.com/pleatman

As a surgeon doing bariatric as well as other general surgeon, I was shocked to read the suggestion that the surgoen insure the patient against future medical bills. When I do an operation such as LapBand or gastric bypass, I promise my patients that I will take care of them and not charge any more for problems after the surgery, but there is no way that I can afford to pay for all their future medical expenses relating to complications. Hospital bills can be astronomical, especially in the USA. That's why we prefer to take care of patients with insurance, as we don't want to put our patients in the poorhouse as a result of an unforseeable complication. Enough about that. I know Dr. Ortiz well... he trained me as well as numerous US surgeons. I have seen his clinic and watched him operate in Tijuana, and I would recommend him to anyone. We all have complications. It's a fact of life. There is a saying that the only surgeons who don't have complications are the ones that don't operate. If your band has eroded, get on with your life. Stop obsessing about your Band. You might consider having a gastric bypass or sleeve gastrectomy. Mark Pleatman MD www.laparoscopy.com/pleatman

Regarding conversion from Band to Bypass: If your insurance company covers the Band, they will generally cover the conversion to Bypass, especially if there have been problems with the Band. Even if you only have 50 more pounds to lose, it may be worth having a conversion if your only other option is removal of the band... because otherwise you will regain all the weight. Mark Pleatman MD www.laparoscopy.com/pleatman

There is such a thing as "Dynamic Slippage," where a slipped band un-slips after it is unfilled. It may stay unslipped for a long time as long as it is not refilled. There is probably no urgency about doing something, though there is no reason to wait. Slipped bands can generally be fixed immediately... there is no reason at all to wait. You can use the same band again, as long as you don't damage the band while dissecting the adhesions (scar tissue)around it. I take care of a fair number of patients who have been banded in Mexico, and try to be sensitve to money issues. I am very nervous about repairing slips and risking re-slippage; I have one patient now whose band I did with Dr. Ortiz, and she now has a dynamic slippage. She wants it fixed. I'll to my best to do what she wants, but my preference would probably be to convert to gastric bypass. It's cheaper and doesn't fail. So far I have coverted 14 band patients to bypass... for various reasons such as slippage, erosion, or just failure to lose weight, and all are happy now. Mark Pleatman MD www.laparoscopy.com/pleatman 248-334-5444

Just a thought for those of you who have suffered band erosion... and please don't flame me! Once you have had an erosion, the anatomy in that area is distorted, and placement of a new band won't be easy. For this reason I recommend lap gastric bypass for patients who want something done. I do it 6 months after removal of the eroded band. It will be more reliably successful than another attempt at a band. That's just my opinion. Mark Pleatman MD www.laparoscopy.com/pleatman

Penni: Actually it's generally the other way around... band erosion leads to infection at the port site. The bacteria migrate from the stomach along the catheter out to the port. I've never heard of port infection causing a band erosion. Band erosions present themselves in 2 ways: 1. no symptoms at all except for loss of restriction, and weight gain. 2. Port site infection Mark Pleatman MD www.laparoscopy.com/pleatman 248-334-5444

Your analogy to the tree is reasonable. The fact that patients tolerate band erosions without getting sick implies that it is a gradual process, with the body walling off the entire process and preventing gastric Fluid from leaking out into the abdominal cavity. I have even seen a presentation on how to remove the eroded band with a gastroscope placed through the mouth! But if you take the band out through the abdomen, whether open or laparoscopically, there will still be an opening into the stomach, and the adhesions formed by the body to wall off the process will be disturbed, requiring you (the surgeon) to close the hole to prevent leakage. By the way, I read the abstract of that article, and it also mentioned that 11 of 16 patients develped fever after the surgery, requiring antibiotic therapy. I'm not sure I would want to risk that in my patients. Mark Pleatman MD

By definition the integrity of the stomach is always compromised in cases of erosion. There is a hole in the stomach, and the band is partly inside it! Here in the USA we worry more about the medico-legal issues. If the new band gets infected, our patient will be very unhappy. My personal opinion is that the patient will be better off with a different operation after an erosion. There is so much distortion to the anatomy that a band just is no longer a good choice. Think about it... most surgeons consider previous antireflux surgery to be a contraindication to band placement. There's a heck of a lot more scarring and fibrosis after band erosion than after a Nissen fundoplication done for reflux. Mark Pleatman MD www.laparoscopy.com/pleatman

North Oakland Medical Centers has opened a Bariatric Center. I am the Program Director. We will be doing LapBand as well as lap gastric bypass, including revisions. We do not have any program fees. We accept patient who have been banded elsewhere. I will continue to run my private practice separately from the Bariatric Center, though time will tell whether or not I put myself out of business! Mark Pleatman MD www.laparoscopy.com/pleatman You can contact the Bariatric Center at 248-857-7346

There's a difference between rejection and infection. Rejection is a term generally used when referring to transplanted organs, which contain antigens that are recognized by the body as foreign tissue. The body's immune system then produces antibodies to destroy the foreign substance. Silicone rubber is of course a foreign substance, but the body does not mount an immune response to it. Infection, on the other hand, is generally related to bacteria. If your port site gets red and inflamed, it is due to infection (or possibly erosion, where the infection tracks along the band out to the port). My understanding of erosion is that it is caused either by sutures too tight around the buckle, or having the band too tight for too long. Mark Pleatman MD Bloomfield Hills, Michigan 248-334-5444 www.laparoscopy.com/pleatman

I don't have statistics on American vs. Mexican surgeons. What is known is that band erosion may be related to suturing technique. Early on in the band experience it was observed that sutures were required to prevent band slippage. Some surgeons went "overboard" placing many sutures to prevent slippage. If too many sutures are placed near the buckle of the band, erosion can occur at this point. I would speculate that since Mexican surgeons started doing lapband well before we did in America, perhaps their earlier cases may have been at risk for erosion. I have removed one band placed in Mexico 5 years ago. That patient was converted to gastric bypass. The only surgeon I know of who will put in a new band immediately after removing an eroded band is Paul Obrien. Most other surgeons will not risk putting in a new band at the same time. Mark Pleatman MD Bloomfield Hills, Michigan 248-334-5444 www.laparoscopy.com/pleatman

I do fills for patients banded elsewhere. I charge $250 for the first fill and $150 for subsequent fills. The first fill costs more because I spend more time collecting information and providing education on what to expect from fills. I use ultrasound guidance in the office to find the ports if I need to(no extra charge), so x-ray is usually unnecessary. Others charge $1000 just to discourage people from coming, and to punish them for going to Mexico. Mark Pleatman MD Bloomfield Hills, Michigan 248-334-5444 www.laparoscopy.com/pleatman

Well, I can't claim to be the best doctor in Michigan; but I think I'm pretty good I do both band and bypass, and also take care of patients who have had surgery elsewhere. I have information sessions on a regular basis... one coming up Thursday Oct 27. The schedule is posted on my website at www.laparoscopy.com/pleatman Mark Pleatman MD

You should always let your physician know if something is bothering you. I would suggest, though, that the problem was not with the sedation, but with the inappropriate comment by the resident. It's actually called "conscious sedation," which means that you are not completely asleep. The goal is for you to be comfortable, relaxed, and not in pain. That goal was achieved. Sometimes residents forget that you are awake and they say things they shouldn't. Mark Pleatman MD

Hi all. One of my patients suggested that I "formally" introduce myself here, as there are a number of comments about me, and it would make sense for me to answer the questions myself rather than have others answer them for me. I have specialized in laparoscopic surgery since 1989, and have been doing bariatric surgery for the past 3 years. I do both LapBand and Lap Roux-en-Y gastric bypass. I've done about 130 of each procedure. I've always tried to be cost-effective, minimizing the use of expensive disposable instruments. After doing a number of procedures, I approached the administration at one of my hospitals and asked them to review my cases and come up with a package price for patients without insurance coverage who would be willing to pay cash up-front. Fortunately my complication rate is very low, and patients often are discharged from the hospital within a short time of their surgery. We are currently offering a package price for LapBand of $12500, and $11,000 for Lap RNY. This includes hospital, anesthesia, surgery, and 2 years of follow-up, including fills. I also do fills for patients who have had there surgery done elsewhere, as well as take care of issues such as slippage, erosion, and port problems. You may be asking, "What's the catch? Why is he so cheap?" Well, the fact is, my surgical fee is actually not cheap. I'm charging $5000 for the surgery and follow-up, which is actually somewhat more than most insurance companies pay. It is the hospital that is sacrificing their profit in exchange for increased surgical volume. Why am I willing to take care of patients of other surgeons? I just figure that it is good business. If you are happy with me, you will refer your friends or family. Please visit my website if you have further questions. I've put together a LapBand FAQ, and would welcome other questions so that I can make it more comprehensive. Sorry if this is long-winded. Mark Pleatman MD Bloomfield Hills, Michigan www.laparoscopy.com/pleatman 248-334-5444

One reason to use fluoroscopy is if you are having trouble accessing the port, but that is pretty rare. The other reason cited by those who do is to give a bigger fill. What they do is fill the band too tight, then give barium by mouth and watch it go down. They then start to empty the band to the point where the barium starts to go through. This way they can get to the ideal fill volume with less tries. This might be a good idea if you are flying to Mexico to have your fill, but it turns out that it still doesn't work that well. You can still get it too tight or too loose with this method. Besides, fluoroscopy generally requires an expensive visit to the hospital where the xray machine is. You don't need fluoroscopy to see if there is a leak, because we always empty the band with each fill, checking to see that everything we put in last time is still there now. I've never seen a slow leak. If there is any leak at all the band will be empty. The world's foremost authority on LapBand is Paul Obrien (from Australia). He doesn't use fluoroscopy. He just does small fills incrementally until the band is just right. That works for me too. Mark Pleatman MD www.laparoscopy.com/pleatman

First of all, you have to individualize for each patient. I start by asking a few questions. Are you vomiting? Do you have restriction? How long until you get hungry? ARE YOU LOSING WEIGHT? If you are losing 1-2 pounds a week, I will be reluctant to do a fill, since you are doing fine with weight loss. For patients who are not losing weight, I will do a fill unless they are vomiting frequently or are significantly restricted. Then we will explore why they are not losing; are you exercising? eating the wrong foods? Drinking liquids with calories? Assuming that you are not losing weight, are not vomiting, and not restricted, this is how I do fills: First fill for 4 cc band: 1 to 1.5 cc depending on whether or not there is any restriction at all. Subsequent fills are about 0.5 cc until we reach 2 ml. After that I go very slow, about 0.25 cc per fill. I have no patients with "full" bands. The highest I have gone is 3.1 ml. For VG or Vanguard bands double all the numbers listed above. I REALLY like to avoid overfilling bands, as it leads to problems. Currently there is no data showing an advantage for fluoroscopy adjustments. Slow and steady is safe and works. Hope that helps. Mark Pleatman MD www.laparoscopy.com/pleatman

When they first started placing these bands, they used the "perigastric" technique, whereby the path behind the stomach went directly along the wall of the stomach. This led to may band slippages of the back wall of the stomach. The pars flaccida technique was developed to prevent posterior slippage or prolapse. The band is placed higer up, actually above the peritoneum. This makes it almost impossible to get a posterior prolapse. This has nothing to do with the anterior sutures which are always placed to prevent anterior prolapse. Mark A Pleatman MD

The LapBand itself costs $3000, but disposable instruments and staples for gastric bypass cost only about $1500. It does take more time to do the bypass, but for some reason the hospital doesn't worry about it. My surgical fee is the same for each procedure because I don't want patients picking based on cost. Also the LapBand is a LOT more work to take care of because of all the fills, which are included in the fee. Bypass patients are very easy to take care of because they don't need anything! Mark Pleatman MD