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About Vanguard Surgical

A practice built around one disease

Dr. Michael Hughes left a professorship and three directorships at the University of Louisville to build a practice devoted entirely to gastroparesis.

“I left the University of Louisville and started Vanguard Surgical to focus exclusively on helping those suffering from gastroparesis.”

He didn’t set out to do this

During his five years of medical school at Wake Forest University School of Medicine and seven years of general surgery training at the University of Virginia, Dr. Michael Hughes never knowingly treated a patient with gastroparesis. He isn’t sure he ever met one, though many were likely never diagnosed.

He was introduced to this miserable, debilitating disease unexpectedly. During his two years of abdominal transplant fellowship at the University of Minnesota, he learned to place gastric stimulators — not as a gastroparesis specialist, but because type 1 diabetics receiving pancreas transplants needed their gastroparesis controlled to avoid rejection. The stimulator was a tool in service of a different operation.

He came to the University of Louisville in 2010 as Director of Pancreas Transplantation and began placing stimulators there for his pancreas transplant patients. Around the same time, Dr. Thomas Abell — the grandfather of gastric stimulation — arrived from the University of Mississippi and convinced Dr. Hughes to help manage his non-transplant gastroparesis patients.

Together they built what became, by volume, the busiest gastroparesis program in the world.

Why he left

Two things happened at once.

The gastroparesis practice grew until it could no longer coexist with transplant surgery. Both are demanding; neither tolerates being a part-time interest.

And Dr. Hughes became a single father raising his children on his own. Transplant surgery — unscheduled, often outside normal hours, governed by when organs become available — is not a career that accommodates that.

So in 2019 he left academic medicine, resigned an associate professorship and three directorships, and founded Vanguard Surgical to do one thing.

Most surgeons who treat gastroparesis treat many other things. Gastroparesis patients end up as the difficult cases wedged between those much easier to manage. At Vanguard, they are the entire practice.

What changed once he could focus

Working only on gastroparesis surfaced a pattern he had been missing.

The standard sequence had been medication first, then a gastric stimulator, then a feeding tube if the stimulator failed. Dr. Hughes followed it — it was what the field did, and it was what he had been taught.

Then he began performing pyloroplasty on patients who already had stimulators. Those patients did better on markedly lower settings. Some no longer needed the stimulator at all; a handful had theirs removed entirely.

“I felt that this was completely backwards.”

He reversed the order, start with pyloroplasty rather than gastric stimulation for all patients. Roughly two in three improve enough that no stimulator is needed. About one in three go on to stimulation, usually for nausea that persists once the pressure problem is solved.

As he treated more and more patients, he found that some patients did not benefit from pyloroplasty and should have proceeded directly to gastric stimulation. These patients had severe nausea and vomiting without significant bloating, fullness or pain. They did not have a stomach under pressure problem. More likely, they had an isolated vagus nerve problem.

Pyloroplasty decompresses the stomach. Patients with bloating, fullness and pain have a stomach under pressure. Pyloroplasty relieves this pressure. As the stomach pressure increases, the vagus nerve is activated which can cause nausea and vomiting, cold sweats, and/or low blood pressure. Decompressing the stomach with pyloroplasty improves these symptoms in two in three patients, likely by reducing vagal nerve activation.

For one in three patients, these symptoms do not improve after pyloroplasty. Similar to those without a stomach under pressure, they are left with an isolated vagus nerve problem, as if the vagus nerve remains on “auto-fire”. For these patients, gastric stimulation is very effective shutting down the vagus nerve and controlling symptoms.

the one thing worth understanding

The nausea and vomiting come from the vagus nerve. Think of it as a smoke alarm wired to your stomach.

Normally the alarm goes off for a reason. Food and air build up behind a pylorus that won’t open, the stomach stretches, and the stretch trips the alarm. You get nausea and vomiting, sometimes cold sweats or a drop in blood pressure. And you feel the pressure itself — bloating, fullness, pain.

Pyloroplasty removes the trigger. Open the pylorus, the pressure drops, the stretching stops, the alarm quiets. That is what happens for about two in three patients.

For about one in three, the alarm is stuck on. The fire is out and the window is open and it is still shrieking. There is nothing left to decompress, so the answer is to turn the alarm down directly. That is gastric stimulation.

And some patients arrive with the alarm already stuck on and no pressure at all — nausea and vomiting, but no bloating, no fullness, no pain. Nothing to decompress. Those patients skip the pyloroplasty entirely.

This is why the same two symptoms can call for two completely different operations. What tells them apart isn’t a test. It’s the company the nausea keeps.

Feeding tubes, once a regular necessity, are now rare — which is the clearest evidence that the steps before them are working.

The part most practices skip

During a stimulator placement, Dr. Hughes removes a small wedge of stomach wall and sends it to pathology to count the remaining pacemaker cells (interstitial cells of Cajal; CD117), nerve cells (myenteric plexus neurons; S-100), and muscle scarring (fibrosis).

That count is not academic. It tells him how much functional tissue is left, which tells him how aggressively to adjust the device in clinic. A badly damaged stomach needs more aggressive adjustment to reduce the amount of time and number of clinic visits. A stomach in better shape needs a less aggressive approach, so the battery isn’t spent unnecessarily.

The pathologists also quantify markers of abnormal immune system activation (CD68 and mast cell tryptase). If these are elevated, then Dr. Hughes knows to aggressively investigate for possible autoimmune gastrointestinal dysmotility (AGID) and other autoimmune disorders such as rheumatoid arthritis, systemic lupus erythematosus, Sjogren’s syndrome, systemic sclerosis, and other mixed connective tissue disorders. As a transplant surgeon, Dr. Hughes is an expert in managing the immune system.

By the numbers

  • More than 4,000 gastroparesis operations over his career — gastric stimulators and pyloroplasties combined
  • More than 2,500 patient encounters over the past year
  • 8 leaks in roughly 2,000 pyloroplasties — under half of one percent
  • The Enterra gastric stimulator was approved by the FDA in 2000. This is established treatment, not experimental

Career totals as of 2026. Individual results vary; no surgical outcome can be guaranteed.

Credentials

Michael G. Hughes, Jr., M.D. President and Attending Surgeon, Vanguard Surgical LLC

  • Board certified in General Surgery
  • American Society of Transplant Surgeons certification — liver, kidney, and pancreas transplantation
  • B.A. in English, Wake Forest University
  • M.D., Wake Forest University School of Medicine — elected to Alpha Omega Alpha as a junior
  • General surgery residency, University of Virginia
  • Abdominal transplant fellowship, University of Minnesota
  • Formerly Associate Professor of Surgery, University of Louisville
  • Formerly Director of Pancreas and Islet Transplantation, Director of Living Donor Transplantation, University of Louisville
  • Consultant to Enterra Medical, training and advising surgeons on gastric stimulator placement and management

Working with insurance, not around it

Denials used to be routine in gastroparesis care. They have become infrequent — but they still happen, and a denial is not the end of the conversation. Dr. Hughes handles peer-to-peer reviews himself, getting on the phone with the insurer’s physician to explain why a patient needs the operation. If necessary, he appeals the denial.

Patients still arrive having been told no. Often that no can be overturned. The team ————

Taylor Rich, APRN

Family Nurse Practitioner

Taylor joined Vanguard in 2023 and assists with the medical management. Board-certified through the American Academy of Nurse Practitioners, she brings more than a decade of emergency and endoscopy nursing at UofL Health — including seven years caring for endoscopy patients in the ambulatory setting. She earned her MSN from Spalding University with a 4.0 and received the Mother Catherine Spalding Nursing Leadership Award. BSN, Bellarmine University. B.S. in chemistry, University of Louisville.

“I brought on Taylor to do a lot of the clinic work and to be the big brain in the operation. Patients love her and she does a great job. We work together to determine the best path forward, particularly for very complicated, fragile patients. Oftentimes, two dedicated health professionals need to challenge each other, sometimes thinking ‘outside the box,’ to arrive at the safest and most effective strategy.”

Phyllis Kaiser, R.N.

Registered Nurse

Phyllis came with Dr. Hughes from UofL to start Vanguard Surgical. She worked as a nurse coordinator for over 23 years managing complex, chronically ill patients in the kidney, liver, and pancreas transplant programs. She worked alongside Dr. Hughes as his nurse coordinator when he created and grew the Pancreas Disease Program.  She understands the challenges of living with gastroparesis and enjoys assisting patients in dealing with their symptoms.

Michelle Sinclair, MA

Office Manager

More than 20 years in healthcare, now focused on giving Vanguard patients relief from gastroparesis, with a personal understanding of how the disease affects daily life.

Michaela Freeland

Medical Office Associate

Michaela has been with Vanguard since the practice opened. She is the first person most patients speak to, and she makes sure each one reaches the right member of the team and gets seen and evaluated without unnecessary delay. Michaela has more than 20 years in the medical administrative field.

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