Calling all (TGVP) people!!! new procedure

[NotSoLittleMermaid 14]

My doctor is doing it at the same time.

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

LapBandTalk Click to visit the largest Lap-Band community online!

[NotSoLittleMermaid 14]

Oh, and I am NOT getting the lapband, I am getting the Gastric Plication Sleeve.

[DrWatkins 13]

Hi

It's November 8th, thanks for the welcome. I was hoping someone would point me in the right direction re. reflux and hiatal hernias. It appears the surgeonwho is operating is prefers not to carry out the TGVP if the hernia is larger than 2cm and due to my reflux? I thought that weight loss would help with hernia's? Anyway he is going to do an endoscopy but if I insist on proceeding will have me sign some sort of liability waiver re. potential for hernia/reflux problems continuing or worsening. I'd love appreciate any insight upon this, then at least I can go ahead and decide better informed.

Thanks Again Regards

Repairing hiatal hernias is very important with any weight loss surgery. The presence of a hiatal hernia shouldn't contraindicate surgery, it should just be repaired at the time of surgery. Certainly if a surgeon doesn't repair hiatal hernias then they shouldn't do a weight loss operation.

One thing I have learned after doing weight loss surgery for 8+ years now is that ALL patients who have been overweight have a hiatal hernia or at best a weak hiatal area. In my opinion, all patients should have the hiatus explored and stitched to the appropriate size as part of all weight loss operations. Without this, patients have severe reflux (heartburn) after weight loss surgery and it reduces their weight loss success and greatly increases their frustration level.

What I have learned is that you have to explore the hiatus, not just glance at it to appreciate how lax the hiatus becomes after being overweight. Overweight is associated with chronically elevated intra-abdominal pressure that continues to dilate the hiatus over time. Too many surgeons ignore this fact during weight loss surgery to the great detriment of the patient.

I have fixed many large hiatal hernias (two very large ones this week!) at the time of weight loss surgery (band and plication and band over bypass) and this does wonderful things to how well the patient does after surgery in terms of maximizing their weight loss success and minimizing their frustration.

I would say that you could have plication with a large hiatal hernia so long as the hernia is repaired at the time of surgery. We do this every day in our patients.

Brad Watkins MD

[letmeeatcake 0]

Thank you all so much, especially Dr Watkins for the informative medical advice. They always say the best surgeons are the ones who assist in answering all your questions.

I am booked in with Dr Fried and wlll endeavour to discuss this further with Dr Martin Fried at our consultation and come back to you all with the advice he gives. I did some research and found several places, including India, Mexico, and the USA, offered the plication but chose Europe due to the ease of travel and locale, especially as I have four young children and wish to get back to them asap.

Warm Regards

[JoanieW 13]

Hi

It's November 8th, thanks for the welcome. I was hoping someone would point me in the right direction re. reflux and hiatal hernias. It appears the surgeonwho is operating is prefers not to carry out the TGVP if the hernia is larger than 2cm and due to my reflux? I thought that weight loss would help with hernia's? Anyway he is going to do an endoscopy but if I insist on proceeding will have me sign some sort of liability waiver re. potential for hernia/reflux problems continuing or worsening. I'd love appreciate any insight upon this, then at least I can go ahead and decide better informed.

Thanks Again Regards

I don't know what size my hernia was, but it was fixed during surgery. I don't see why a large hernia couldn't be fixed, as well. Are there any doctors closer to you where you can get a second opinion?

[letmeeatcake 0]

None that I am aware of. aNYONE KNOW OF tgvp surgeons in or around the UK. Good to know you have had yours repaired. HOW are you doing with the weight loss and in general, i always think a large part of the journey is as psychological as it is physical.

Best Wishes:biggrin0::scared0:

[letmeeatcake 0]

Here is just some information that is probably already out there.

Please let me have your thoughts/opinions on this.

Apologies if there are any errors, again just give me a heads up.

My surgery is with Prof Fried he comes well recommended and certainly seems to be an expert in the gastrointestinal/gastroentrological field. Though I am a little concerned that there is no specific suturing device being used!

I checked out the doctors in Mexico, USA AND INDIA and most are well versed/good at the procedure, they tend to use the correct number and size of incisions to go in laproscopically i.e. 1, 10mm and the others 5mm; they also look at the individuals stomach to determine the narrowness of the tube/bougie size, ranging from 32f through to 42f, possibly there are larger bougies out there; though some stick with one tried and tested bougie size usually 34f to prevent stomach twisting, slippage into chest cavity, reflux etc.

Prices vary with the USA being the most expensive around $9,000-$13,000 dollars unfortunately that is also where some of the better surgeons are, I suppose you the old adage "you get what you pay for," is true; through to Mexico and Europe being mid range around $ 8-9000 dollars and approx ? 6,500 if you consider the higher end of the exchange rate, this would include price of flights and accomodation and finally India being the cheapest, around $ 5- 7000 approx ?4000- ?5000 British pounds again depending on Rs/currency fluctuations and which clinic you attend including flights and accomodation.

Most take a full medical profile but not all and follow the NIH (National Institute of Health) or British equivalent (NICE )guidelines re. BMI and Co-morbidities. Many good surgeons also perform an thorough OGD endoscopical check to ensure that there are no nasty surprises lurking within your abdomen that could cause future discomfort or pain, i.e. ulcers and hiatal hernias. I understand patients are advised accordingly and any size of hernia is fizxed/sutured up accordingly to prevent further heartburn/reflux.

I understand that by and large sutures are made of varying non absorbable materials i.e. PDS and that the surgeons tend to apply at least two layers of Prolene running sutures using the Endoflip device by Crospon, again not every imbrication surgeon is authorised to use this device as it isn't being marketed everywhere yet and you will need to check, i.e some clinics in India and Europe are using the old needle thread holder and grasper.

The stomach retains viability and therefore the procedure is reversible, the few that have had a reversal have been due to early complications such as prolonged nausea that has affected the individual and may have had an impact on the stitches? There does not appear to have been any dihension, loosening away or give in the stitches thus far.

Furthermore though there have been some concerns about the stomachs elasticity it is thought that as the greater curvature, the elastic part, is being reduced and folded into itself and that the remaining inner sleeve is both smaller/narrow and generally considered to be the firm part of the stomach, that stretching of the stomach or dihension of stitches, shouldn't really be an issue as long as you try to stick to the dietary guidelines and stop eating just before you feel full.

Pre op guidelines tend to be similar to other weight loss surgeries and are both dependent upon your surgeon/clinic and BMI. Though I always think it is is a good idea to try and shrink your liver.

Post op dietary guidelines are as follows:

1st and 2nd Week after TGVP

Clear broth or Soup without vegetables or meat and not too creamy.

Low fat, sugar free yogurt.

Skimmed milk.

Natural fruit juice or pureed soft fruit (apple, banana, pear, etc).

Vegetable juices.

Low calorie drinks.

sugar free Protein supplements, with skimmed milk.

Water ( 6-8 cups / 2.0- 3.0 liter a day).

In between meals we recommend that you drink vegetable juice, milk, fruit juices, and Water, to ingest sufficient liquids and prevent dehydration

3rd and 4th Week

More liquid/pureed diet included in your meals during week 3 and 4 after the TGVP, to assist in adapting to smaller stomach

How can I prepare a pureed diet?

This may be a challenge for you. You will need a blender or food processor. The food has to be blended until reaching a Gerber or applesauce consistency.

Avoid spicy flavours; they may irritate your stomach.

Use the following list to give you an idea of what

you can eat on weeks 3 and 4:

Liquids or beverages, and milk.

Good options: Tea, non-carbonated drinks, natural fruit juices, Crystal Light, coffee, water, skimmed milk, low fat and sugar free yogurt.

Limit or try to avoid: Artificial fruit juices, soda, alcohol, all carbonated beverages, iced tea with sugar, milk or yogurt products with nuts or seeds, chocolate milk, sweetened condensed milk, whole milk.

Fruits.

Good options: Applesauce, pureed pears, and bananas.

Limit or try to avoid: Canned fruits or fruits with Syrup.< /p>

Vegetables.

Good options: Pureed vegetables, vegetable juice.

Limit or try to avoid: Raw vegetables, canned vegetables, vegetables that cause discomfort (gas forming).

Soups.

Good options: broth, cream Soups make with skimmed milk, egg drop Soup, low sodium bouillion or consomm?.

Limit or try to avoid: All others.

Starches.

Good options: Mashed potatoes.

Limit or try to avoid: bread, Pasta, rice and all other starches.

meats or Protein supplements.< /p>

Good options: Pureed chicken, fish, tuna, veal, beef, low fat cottage cheese, baby food meats, mashed or pureed tofu, pureed egg or egg substitute, sugar-free Protein shakes like Designer’s Protein, Boost Breeze, no sugar added Carnation Instant Breakfast.

Limit or try to avoid: Peanut Butter, others.

Fats, sugars and others

Good options: Sugar free gelatine, sugar free popsicles, pudding.

Therafter general recommendations are as follows:

Eat three small meals a day and limit snacking in between meals.

Eat slowly and chew food until it reaches a mushy consistency

(15 to 20 times per bite).

Stop eating or drinking right before you feel full.

Eat only good quality foods.

Drink low calorie liquids.

Drink enough liquids /about 2.0 – 3.0 litres per day .

Drink after eating.

Exercise moderately, however not sooner than 2 weeks after

TGVP procedure.

Limit: Others.

Note foods high in fat, acid, sugar and stodgy foods are to be avoided due to calorific content and problems with bloating and digestion, as well as their potential for heartburn and reflux. Carbonated drinks are to be avoided because they contain too much fizz and cause an explosion type effect in your stomach causing problems with gas and of course they are also corrosive and there may be some concerns that their explosive effects may have an impact on stretching the stomach?!! Though if you do desire these they appear to have been known to be consumed in small quantities or after the drink had been left to breathe for a couple of hours thereby disposing of some of the bubbles.

Most hospital keep patients for approx two days to monitor them. I think there are some really good surgeons and these are as include, Dr Daniel Cottam, Dr Sunil Sharma, Dr Mahinder Narwaria, Dr Brad Watkins, Dr Lopez Corvala, Dr Jose Rodriguez etc apologies to anyone I may have missed off my list. Anyway I could chunter on forever, however my little ones are demanding my attention. I hope this information helps, please do not take it all as read and set in stone this is just my own research, the whole point of this site is to get better equipped by talking to experts who are willing to give up their valuable time and assist with putting this procedure out there and others intending to or that have already undergone the procedure.

Finally the procedure remains in its infancy and like the sleeve we have no longer term data or comparisons of longer term weight loss, or health issues or reduction in ghrelin levels to go on, though it seems to be working.

Warm Regards

Cake is my favourite food

Edited September 16, 2010 by letmeeatcake

[JoanieW 13]

None that I am aware of. aNYONE KNOW OF tgvp surgeons in or around the UK. Good to know you have had yours repaired. HOW are you doing with the weight loss and in general, i always think a large part of the journey is as psychological as it is physical.

Best Wishes:biggrin0::thumbup1:

I have had great weight loss. As of last Sat. and including my one week preop diet, I have lost 24 pounds. You are right, the journey is both psychological and physical. I now understand why this is just a tool. You still have to watch what you eat to get the weight off. You don't want to be eating chips, ice cream, and Cookies. The good part is that I am satisfied on a lot less, and I think I can keep the weight off a lot easier than in the past. Thank you for the well wishes.

[JoanieW 13]

Letmeeatcake (love your name), I suggest you click on Dr. Watkins name in his last post and read all his posts. I think you will find a lot of your questions have already been answered by him, and you can trust what he says. Let me know if you have any others about my personal experience, and I will be happy to answer them.

[letmeeatcake 0]

Thank you for your offer of help with your own personal journey and I will definitely click on Dr Watkins name, I feel like I am finally getting somewhere.

Regards

LETME

[letmeeatcake 0]

HEY CONGRATS on the weight loss that is fantastic news I know what you mean about feeling full on a lot less. How much further do you have to go? Have you adopted any sort of exercise regimen or is the weight loss purely down to lower food intake down to your good food choices and that feeling of satiety with the help of your procedure?

Regards

LetmeGimmee

[JoanieW 13]

HEY CONGRATS on the weight loss that is fantastic news I know what you mean about feeling full on a lot less. How much further do you have to go? Have you adopted any sort of exercise regimen or is the weight loss purely down to lower food intake down to your good food choices and that feeling of satiety with the help of your procedure?

Regards

LetmeGimmee

Thanks, Letme. I wanted to lose 60 pounds, so I have 36 more to go. Hopefully that will be even less when I weigh myself on Sat. I'm ashamed to say, I haven't been doing very much exercise. I walk in the morning sometimes, but I could do a lot better. I just hate to exercise.

[letmeeatcake 0]

Hey I know what you mean about exercise... tho at one stage I was a gym bunny. Now the only exercise I seem to get involves running around and picking up after the kids and the occasional game on wii fit.

Let me know how the weightloss is going and keep me peeled re. any bumps in the road, I think it helps to have support.

I'm beginning to feel a little nervous now, still plenty of time to go tho...

Letmehavemycakeandeatitaswell

letthemeatcake!

[MS LISA 1]

Hey I know what you mean about exercise... tho at one stage I was a gym bunny. Now the only exercise I seem to get involves running around and picking up after the kids and the occasional game on wii fit.

Let me know how the weightloss is going and keep me peeled re. any bumps in the road, I think it helps to have support.

I'm beginning to feel a little nervous now, still plenty of time to go tho...

Letmehavemycakeandeatitaswell

letthemeatcake!

Hi there Letmeeatcake,

I was just wondering when are you going to get your plication surgery? and who will be your doctor?

I am going to get mine in novemeber Dr rodriguez yay!!!

Lisa~

[letmeeatcake 0]

Hey Lisa

That sounds gr8 my surgery is on the 8th of November with Professor Martin Fried. How are you feeling? Will you be taking someone with you?

Regards

Letme