GPS Update

[DrWatkins 13]

GPS is a very hot topic in the bariatric surgery community and growing every day. I am now starting to train other surgeons on the procedure and the demand for this is increasing as patients request GPS and surgeons want to learn how to do it. I have visited several U.S. surgeons that also do GPS for the benefit of sharing information and maximizing our collective knowledge about a new procedure. We share information on a regular basis for the benefit of our patients. Last week I visited a prestigious academic center that has started offering plication as well. When we first started, our patients were having a hard time pronouncing and remembering terms like imbrication and plication so I asked my wife what we should call it and she suggested GPS for Gastric Plication Surgery because it was easy to remember. This term seems to have caught on and now I see even international surgeons use the term.

There does not seem to be agreement about the bougie size (bougie being a soft rubber tube used to size the new stomach sleeve). I have a strong opinion that the sutures (stitches) should be interrupted (individual stitches with a knot tied at each location) as opposed to a running stitch (knot tied at each end of a long stitch taking many "bites" along the way much like sewing. With interrupted stitches, the tension is controlled at each knot. With a running stitch, the tension is not controlled and can get too tight and lead to stomach tissue necrosis and/or perforation which we have all read about on this board. Another part of this is not to place the suture too deeply. In surgeonspeak, the suture should be seromuscular, not full-thickness. I also have a strong opinion that the ideal stitch is 2-O Ethibond. This is a third generation silk that actually causes a bit of scar tissue (favorable) which makes the bond stronger than just the stitch itself. Ethibond has been around for many years plicating the stomach for other reasons and it holds really well. I have seen Prolene used which is a monofilament suture and causes no reaction and actually doesn't hold its knots as well (poor suture memory as we call it) which means the knots can come undone. I think Prolene is at too high of a risk for prolapse where the whole thing resorts back to the normal stomach size or even worse where only one section is herniated out and could cause problems. I also feel strongly that the sutures should be no more than 2-3 centimeters apart from one another. I've seen surgeons place their stitches much further apart and I think this again increases the risk for prolapse or the stomach herniated back out between the stitches.

We've learned from doing thousands of band surgeries for the last 9 years the importance of a two week liquid Protein diet prior to surgery to reduce the size of the liver and improve the ease of the operation. The first weight you lose comes out of the liver. I also think it is important to eradicate the known stomach bacteria, Helicobacter pylori because it is ubiquitous, most of us have it in our stomach lining and it can cause ulceration, inflammation or swelling when surgery is done on the stomach. This is easily eradicated with a two week antibiotic regimen pre-op. I think it's important to stay on a liquid diet (pureed Soups, applesauce, Jello, pudding, yogurt) for the first week and soft mushy foods for weeks two and three. Carbonation is a bad idea in any stomach surgery for weight loss because it dilates our work. (Have you ever opened a dropped can of Coke?) The best weight loss is acheived when you avoid drinking liquids for an hour after a meal. This allows you to be fuller sooner and longer and really makes the tool of GPS more effective.

We have found that Levsin (hycosamine) 0.125mg SL (sublingual - under the tongue) given pre-op and continued three times daily post-op dramatically reduces the crampy abdominal pain after GPS. This has really improved the patient experience with this surgery. I also use lots of numbing medicine (local anesthetic) during the surgery which dramatically decreases pain after surgery.

I always scope the stomach during the operation to make sure we're not missing an ulcer or polyp or any other important pathology. I do this in the operating room because it saves doing it as a separate procedure and also the scope is the ideal bougie size so I leave it in for the sizing catheter and this allows me to look at the perfect sleeve I just created when we're done with the procedure. Many surgeons don't do a stomach scope and I worry about doing this with no knowledge of the stomach lining.

There is a lot of debate about stapled sleeve gastrectomy vs GPS. One item of consideration I think is important is that stapled sleeve patients have a 9% incidence of Vitamin B12 deficiency. The stomach makes something called intrinsic factor that aids in the absorption of Vitamin B12. A distinct advantage to GPS is that no stomach is removed and the intrinsic factor levels are not disturbed so you would expect that GPS patients would not have such a high incidence of vitamin deficiency. Stapled sleeve patients are also deficient in several other Vitamins such as Iron, folate and Vitamin D. (Ref: Obesity Surgery 2011, Feb 21(2):207-11.) I think there are many advantages to leaving the stomach in the body - just making it smaller as a powerful weight loss tool. Ghrelin gets a lot of press but it is important to realize that you reduce ghrelin with pressure (food in a smaller stomach). Ghrelin is a feedback hormone so physically removing stomach doesn't eliminate ghrelin.

You guys have seen me rant about hiatal hernias on this board and I continue to feel strongly about repairing this during the surgery. What I've learned is that if you are overweight, there is nearly a 100% chance that you have a hiatal hernia and even if this is small it should be repaired at the time of surgery. Otherwise, you will have terrible heartburn when your stomach is made smaller. I get calls from patients that had GPS elsewhere and they have terrible heartburn and their hiatal hernia was not addressed at the time of surgery and they are pretty miserable. This is avoidable. Hiatal hernias are really easy to fix at the time of surgery so my opinion is that there is little excuse for ignoring this principle.

The latter part of this month, I have a major annual surgical conference and plication is now on the agenda of this meeting. All this to say, I think that GPS is here to stay and gaining in popularity. One of my GPS patients came in the office last week having lost over 70 pounds in less than six months and he is quite thrilled as am I.

That is all the good stuff. To me, the main downside is that the procedure is still new and we don't have long-term data. Two year data out of Europe looks good but we don't have two year U.S. data yet. There is some interesting data from Germany showing dilations ten years after stapled sleeve gastrectomy and I think the GPS can do this as well. We know from other operations that the key to preventing dilation is to avoid carbonation and avoid eating to the point of regurgitation after the stomach is smaller. Whenever something new comes up with GPS I will post it on this board. I also thank you for teaching me. Your experiences that you post here educate all of us.

Keep up the great work. I wish you all the very best of success in your weight loss journey. Don't forget to buy yourself a substantial present when you reach your goal.

Brad Watkins MD

[Lmom1980 29]

GPS is a very hot topic in the bariatric surgery community and growing every day. I am now starting to train other surgeons on the procedure and the demand for this is increasing as patients request GPS and surgeons want to learn how to do it. I have visited several U.S. surgeons that also do GPS for the benefit of sharing information and maximizing our collective knowledge about a new procedure. We share information on a regular basis for the benefit of our patients. Last week I visited a prestigious academic center that has started offering plication as well. When we first started, our patients were having a hard time pronouncing and remembering terms like imbrication and plication so I asked my wife what we should call it and she suggested GPS for Gastric Plication Surgery because it was easy to remember. This term seems to have caught on and now I see even international surgeons use the term.

There does not seem to be agreement about the bougie size (bougie being a soft rubber tube used to size the new stomach sleeve). I have a strong opinion that the sutures (stitches) should be interrupted (individual stitches with a knot tied at each location) as opposed to a running stitch (knot tied at each end of a long stitch taking many "bites" along the way much like sewing. With interrupted stitches, the tension is controlled at each knot. With a running stitch, the tension is not controlled and can get too tight and lead to stomach tissue necrosis and/or perforation which we have all read about on this board. Another part of this is not to place the suture too deeply. In surgeonspeak, the suture should be seromuscular, not full-thickness. I also have a strong opinion that the ideal stitch is 2-O Ethibond. This is a third generation silk that actually causes a bit of scar tissue (favorable) which makes the bond stronger than just the stitch itself. Ethibond has been around for many years plicating the stomach for other reasons and it holds really well. I have seen Prolene used which is a monofilament suture and causes no reaction and actually doesn't hold its knots as well (poor suture memory as we call it) which means the knots can come undone. I think Prolene is at too high of a risk for prolapse where the whole thing resorts back to the normal stomach size or even worse where only one section is herniated out and could cause problems. I also feel strongly that the sutures should be no more than 2-3 centimeters apart from one another. I've seen surgeons place their stitches much further apart and I think this again increases the risk for prolapse or the stomach herniated back out between the stitches.

We've learned from doing thousands of band surgeries for the last 9 years the importance of a two week liquid Protein diet prior to surgery to reduce the size of the liver and improve the ease of the operation. The first weight you lose comes out of the liver. I also think it is important to eradicate the known stomach bacteria, Helicobacter pylori because it is ubiquitous, most of us have it in our stomach lining and it can cause ulceration, inflammation or swelling when surgery is done on the stomach. This is easily eradicated with a two week antibiotic regimen pre-op. I think it's important to stay on a liquid diet (pureed Soups, applesauce, Jello, pudding, yogurt) for the first week and soft mushy foods for weeks two and three. Carbonation is a bad idea in any stomach surgery for weight loss because it dilates our work. (Have you ever opened a dropped can of Coke?) The best weight loss is acheived when you avoid drinking liquids for an hour after a meal. This allows you to be fuller sooner and longer and really makes the tool of GPS more effective.

We have found that Levsin (hycosamine) 0.125mg SL (sublingual - under the tongue) given pre-op and continued three times daily post-op dramatically reduces the crampy abdominal pain after GPS. This has really improved the patient experience with this surgery. I also use lots of numbing medicine (local anesthetic) during the surgery which dramatically decreases pain after surgery.

I always scope the stomach during the operation to make sure we're not missing an ulcer or polyp or any other important pathology. I do this in the operating room because it saves doing it as a separate procedure and also the scope is the ideal bougie size so I leave it in for the sizing catheter and this allows me to look at the perfect sleeve I just created when we're done with the procedure. Many surgeons don't do a stomach scope and I worry about doing this with no knowledge of the stomach lining.

There is a lot of debate about stapled sleeve gastrectomy vs GPS. One item of consideration I think is important is that stapled sleeve patients have a 9% incidence of Vitamin B12 deficiency. The stomach makes something called intrinsic factor that aids in the absorption of Vitamin B12. A distinct advantage to GPS is that no stomach is removed and the intrinsic factor levels are not disturbed so you would expect that GPS patients would not have such a high incidence of vitamin deficiency. Stapled sleeve patients are also deficient in several other Vitamins such as Iron, folate and Vitamin D. (Ref: Obesity Surgery 2011, Feb 21(2):207-11.) I think there are many advantages to leaving the stomach in the body - just making it smaller as a powerful weight loss tool. Ghrelin gets a lot of press but it is important to realize that you reduce ghrelin with pressure (food in a smaller stomach). Ghrelin is a feedback hormone so physically removing stomach doesn't eliminate ghrelin.

You guys have seen me rant about hiatal hernias on this board and I continue to feel strongly about repairing this during the surgery. What I've learned is that if you are overweight, there is nearly a 100% chance that you have a hiatal hernia and even if this is small it should be repaired at the time of surgery. Otherwise, you will have terrible heartburn when your stomach is made smaller. I get calls from patients that had GPS elsewhere and they have terrible heartburn and their hiatal hernia was not addressed at the time of surgery and they are pretty miserable. This is avoidable. Hiatal hernias are really easy to fix at the time of surgery so my opinion is that there is little excuse for ignoring this principle.

The latter part of this month, I have a major annual surgical conference and plication is now on the agenda of this meeting. All this to say, I think that GPS is here to stay and gaining in popularity. One of my GPS patients came in the office last week having lost over 70 pounds in less than six months and he is quite thrilled as am I.

That is all the good stuff. To me, the main downside is that the procedure is still new and we don't have long-term data. Two year data out of Europe looks good but we don't have two year U.S. data yet. There is some interesting data from Germany showing dilations ten years after stapled sleeve gastrectomy and I think the GPS can do this as well. We know from other operations that the key to preventing dilation is to avoid carbonation and avoid eating to the point of regurgitation after the stomach is smaller. Whenever something new comes up with GPS I will post it on this board. I also thank you for teaching me. Your experiences that you post here educate all of us.

Keep up the great work. I wish you all the very best of success in your weight loss journey. Don't forget to buy yourself a substantial present when you reach your goal.

Brad Watkins MD

Thanks for the info Dr. Watkins.

I have been in touch with Pamela, and I am hoping to have GPS in March. I know I need to get the ball rolling, but I was hoping that Cottem would call me back and tell me if He would perform the GPS at the same price as you. It is just my luck that the Dr. who is in my state charges the highest fee, and I simply can not afford him. If he ever does call or email me back, I would also like to know if He would give me any after care if needed. As much as I would love for you to perform the surgery for me, It seems so silly to have to leave my children and fly across the country. Maybe you could give him a hint to contact me and give me a deal. better yet, both of you could do the surgery for me next week when you are here in Utah! Haha...a girl can dream right?

Anyway, Maybe I will be meeting you soon, and thanks again for the GPS tips and info.

L in Utah.

[DrWatkins 13]

Thanks for the info Dr. Watkins.

I have been in touch with Pamela, and I am hoping to have GPS in March. I know I need to get the ball rolling, but I was hoping that Cottem would call me back and tell me if He would perform the GPS at the same price as you. It is just my luck that the Dr. who is in my state charges the highest fee, and I simply can not afford him. If he ever does call or email me back, I would also like to know if He would give me any after care if needed. As much as I would love for you to perform the surgery for me, It seems so silly to have to leave my children and fly across the country. Maybe you could give him a hint to contact me and give me a deal. better yet, both of you could do the surgery for me next week when you are here in Utah! Haha...a girl can dream right?

Anyway, Maybe I will be meeting you soon, and thanks again for the GPS tips and info.

L in Utah.

I agree that it would be nice to have surgery close to home. I will see Dr. Cottam at the meeting so I will see what I can do! After we had done a few GPS cases I flew to Salt Lake to watch Dr. Cottam do cases. I think the hospital where he works is the main difference in cost. Hospitals are very expensive. I am fortunate to work in a surgical hospital which is basically a surgery center with nice hospital rooms where we can keep patients overnight. It is much less expensive because of the differences in overhead. I also don't think we need the endoflip which saves a lot of money. Congratulations on having the biggest surgical meeting of the year in your town.

Brad Watkins MD

[FatToPhat 83]

Thank you, Dr. Watkins, as always, for your wonderful update and valuable information! LMom1980, I live in Idaho and Dr. Cottam is also closer for me and I'm scheduled for consults with him on the 16th of this month. However, I've also been thinking of having Dr. Watkins do mine, as well, even if it does mean a flight across country. Not only is his less expensive, but he certainly seems VERY knoweledgeable and excited about this new procedure. I will tell you that I have had a little trouble with Dr. Cottam's office when I've called. There seems to be a little bit of disorganization and lack of knowledge by the staff. However, the packet of info they sent me was very thorough and their aftercare program seems excellent. They also, try to have you do all your consults and labs, etc. on the same day for efficiency, especially if you're coming from out of state, like myself. If Dr. Watkins can get Dr. Cottam to give you a reduced rate, please let ME know, too! Otherwise, I'm still vacilating between the two!

[Lmom1980 29]

Thank you, Dr. Watkins, as always, for your wonderful update and valuable information! LMom1980, I live in Idaho and Dr. Cottam is also closer for me and I'm scheduled for consults with him on the 16th of this month. However, I've also been thinking of having Dr. Watkins do mine, as well, even if it does mean a flight across country. Not only is his less expensive, but he certainly seems VERY knoweledgeable and excited about this new procedure. I will tell you that I have had a little trouble with Dr. Cottam's office when I've called. There seems to be a little bit of disorganization and lack of knowledge by the staff. However, the packet of info they sent me was very thorough and their aftercare program seems excellent. They also, try to have you do all your consults and labs, etc. on the same day for efficiency, especially if you're coming from out of state, like myself. If Dr. Watkins can get Dr. Cottam to give you a reduced rate, please let ME know, too! Otherwise, I'm still vacilating between the two!

I still have not heard back from Dr. Cottems office. I was a little annoyed when I called and said "I just attended a seminar last night, but I would like to talk to Dr. Cottem about plication." The lady then said "The best thing to do is to attend a seminar." Duh, I just told you that I attended a seminar. They made me fill out this huge form before they would have the Dr. call me. Still....no phone call. Let me know what you decide to do. We can follow each others progress. Good Luck.

[FatToPhat 83]

I still have not heard back from Dr. Cottems office. I was a little annoyed when I called and said "I just attended a seminar last night, but I would like to talk to Dr. Cottem about plication." The lady then said "The best thing to do is to attend a seminar." Duh, I just told you that I attended a seminar. They made me fill out this huge form before they would have the Dr. call me. Still....no phone call. Let me know what you decide to do. We can follow each others progress. Good Luck.

Yeah, that's kind of the response I got the first few times I called, too. In fact they told me that instead of attending a seminar, I could attend a webinar that they were working on getting set up in the next couple of weeks (from the time I called). I waited 3 weeks....no webinar. So, I called back and they transferred me to another person who said they were holding off on the webinar because they are in the middle of moving their office and didn't have time to work on that right now. She also told me because I was out of state that I didn't have to attend a seminar. NOW you tell me! But, I finally got a contact person and her name is Kim, if you want to ask for her directly, you might be able to get a better response. She has been more helpful.