Gastric Banding Rules…and sometimes sleeve

22 Jan

This is a list I created for my patients to help them get out of trouble, and then i thought, “What if it keeps them out of trouble?”

Pardon the almost run-ons! Loads of info to get out. Good rules to follow for great reasons!



  • In general, do not eat or drink 2 hours before sleep. The esophagus works by squeezing food down toward your stomach, and it also works by gravity. So, when you are standing upright, the food goes down and the liquid goes down to the stomach with some squeezing from the esophagus and the effect of staying upright. When you eat something or drink something and then lie down, everything that is above your band, as you lie down, just lays there and then the esophagus squeezes in both directions- toward the Band and the stomach, but also toward the upper chest and your mouth. So, because of that you can get esophagitis or inflammation (swelling). When you have a well-adjusted band, the thing to do is to hold off on eating, drinking and then lying down. You should wait about two hours.
  • There is such a thing as pill esophagitis, and in a well- adjusted Band, your pill should be chewable when you can or a liquid, such as a multivitamins, calcium, but any other pill should be either cracked or, if they are capsules, you should take them between 12pm and 6pm, when your esophagus is more open. This is something you should discuss with the doctor. The other thing is that, if you have to take a pill right before sleep, try and make it at least an hour before sleep and swallow with the minimal amount of water. Also, make sure that it is a small pill, and if it is a large pill, to break it up into smaller pieces.
  • If you find yourself in the position of being too tight, and you have thrown up, before you go ahead and take something else in, try to wait for about 2-3 hours after you throw up and then take a teaspoon of warm liquid, something decaffeinated- could be water, could be a herbal tea,: just take 1 teaspoon – and put it down and see if you can get 1 teaspoon down every 2-5 minutes. You have to time it. When you throw up with the Band, sometimes it tightens on its own. This is because of swelling
  • If you are flying and your Band is well adjusted, some patients seem to get tighter during the flight. We recommend that you go on a general liquid diet before and during the flight as well as for a few hours after you land. The reason is that you can get tighter in the air. This will ensure that you will have a good vacation or business trip when you travel rather than taking something in and having that awful sticking feeling or throwing up and being in a strange location and not being able to get fluid out of your band.
  • If you are throwing up often, try and figure out if it is during a particular time of day. If you throw up more at lunch, try having soups, yogurt or protein shakes for that meal. If it is dinner (and you are home) or if the first bite makes you throw up, perhaps try to drink a little warm fluid, about 1-2 ounces (which is less than ¼ cup) 15 minutes before you are going to eat. This helps to relax your esophagus, and lets it know that you are going to eat.
  • The esophagus responds to extremes of temperature, so you may find that ice-cold and super hot cause you to experience a pain in your chest. The pain is your esophagus squeezing in response to temperature. This is why many patients find that warm or room temperature liquids “go down easier”.
  • Normally, the esophagus is tighter in the morning when we get up. Add a band around the stomach, and the effect can be magnified. As the band is adjusted, many patients find they can’t eat breakfast. Some patients also find they can’t drink anything until 10 or 11 in the morning. When you first get up in the morning, don’t try to and drink something right away. Wait until after you have gotten ready for work and have been upright or standing for about 45 minutes. Then try a sip of coffee or room temperature water and wait 15 minutes before you try to finish your cup.
  • The esophagus also responds to stress and anger! The esophagus squeezes more and gets tighter- So if you are running around trying to multi-task, go with room temperature liquids. Also, for the ladies, the esophagus can get tighter when you have your period. This effect is usually only seen when your band is well adjusted. You ma y need to go on liquids during your period or menses. You may also need to come in and get a little loosened.
  • Remember the old adage: Chew Chew and Chew. We recommend that you chew at least 15 times, then put the fork down and wait 30 seconds. This will let you know if you chewed the food well enough and it will go down OR if it is going to get stuck
  • Please do not wait too long. If you cannot tolerate liquids and you still cannot 24 hours later, come in! If you cannot tolerate your own saliva, make the call to our office early! Don’t try to tough it out! Any delay may necessitate intravenous fluids in the Emergency Room instead of just getting the band loosened in the office and then drinking water yourself to hydrate.

Esophageal function in weight loss surgery

4 Jan

This is an article I wrote for the NYU weight management program newsletter a couple of years ago: I updated it a little.

We have only one esophagus so we have to be really good to it. The esophagus has one job- to squeeze whatever we swallow down to our stomach. The esophagus is a muscular tube which is important to remember. A muscle when used repetitively or when stress is placed on it, can fatigue. So what does that mean? Let’s look at a muscle that we can control like our bicep. We lift a 5 lb weight and after 20-30 repetitions, our bicep gets tired or worn out (I know for some of you superfit people, it may be 50 repsJ). This is important to remember for life with the gastric sleeve and gastric band especially after the band is adjusted.

Another fun fact about our esophagus? The esophagus is more constricted in the morning which means it feels tighter! It also means that the esophagus is “generating a higher pressure” or squeezing more first thing in the morning. Do you feel tighter in the mornings? Can’t get that coffee down first thing? Well that’s normal it turns out! When the esophagus squeezes so hard, it gives you the feeling of something being stuck or of chest pain in the middle of your chest. This has a lot of correlation for patients with gastric banding and also immediately after gastric bypass or sleeve gastrectomy.

The effect of that tightness is magnified when there is a band in place or right after vertical sleeve or gastric bypass. Imagine that your esophagus has to squeeze harder to get food or liquids that you swallow across the band or through the sleeve. The esophagus squeezes and generates a high pressure to get the swallow across the band and into the stomach because the band causes a high-pressure zone where we put it.

Specifically for the band:  When you get a band fill, the esophagus has to squeeze a lot harder to get what you swallow across the band. Many of you notice that you are tighter right after a fill, and then we often hear that the band “loosened”. Well what really happens is right after the fill, your esophagus feels tighter because it’s squeezing to some high pressures. And after a period of time, the esophagus figures out that it doesn’t have to squeeze as hard to get swallows across the band (Fig. 1). The pressure that the esophagus generates doesn’t go down to the same level as before the fill, it stays a little higher. A fill can be too tight because the esophagus CANNOT generate a high enough pressure to get your swallow down (this can be liquids, solid or even your own saliva). Right after a fill, we ask you to be on liquids for two days and puree for two days so that you don’t have a crisis, SUFFER and need an emergency “unfill”. Following liquids and puree format also gives your esophagus a chance to ease into the fill and doesn’t force your esophagus to generate super high pressures. The goal of fills is to try and find a balance between you not being hungry and being able to eat a variety of foods including protein and your esophagus not having to squeeze too hard.

Now, with the sleeve, bypass and band: If you take a big bite and swallow it, the esophagus has to squeeze harder. If you don’t chew your food well, the esophagus has to squeeze harder. If you take a bite and then take another one right away (we call it stacking the swallows), your esophagus has to squeeze harder. If you drink big gulps or chug a glass or bottle of water, your esophagus has to squeeze harder to get that bolus of liquids across the band into your stomach. So what you ask? Well remember that with repetitive use, any muscle can fatigue. When your esophagus gets tired- of all the gulping, and eating fast and not chewing well and trying to wash the food thru the band with liquids- ,it will stop squeezing so hard and be tired. When the esophagus doesn’t squeeze and give its’ all, the esophagus dilates. It can’t generate enough force to get food and liquids across the band, and this can cause esophagitis, reflux, heartburn, fluid coming out of your nose at night and night cough. Then what do we , the docs and clinicians, do? We loosen your band so that the esophagus doesn’t have to squeeze so hard, and it gets a chance to heal. For sleeve and bypass patients, eating behaviors have to change in order to get rid of that feeling of reflux.

Well, that sounds so simple right? Loosen the band, and let you heal! But some of you know that when we loosen the band, you get more hungry or you find that you can eat more. Perhaps the best way of avoiding loosening and dilating your esophagus IS…don’t take too big a bite, don’t stack your swallows (wait 30 seconds between bites ), don’t wash down your food with liquids. Your esophagus doesn’t get irritated because you swallowed too big a bite once, or that you gulped down a ½ liter of water once. It dilates because of repetitive behavior. We have all heard those touchy feely expressions: Be kind to one another or Be kind to the world, it’s the only one we have. Well I have a new one for you: Be kind to your esophagus, it’s the only one you got!

Disordered Eating

4 Jan
I do a weekly radio show and have some really great guests that have some great information. I am going to try to update my blog with shows that relate to weight loss surgery.  I know many of you listen to my show (more of you should!) but for those who do not or cannot, I hope these updates help you learn about some of the great things I do from my show.
Disordered EatingI had a great radio show a few months ago where I had Mindy Gorman-Plutzer, who recently wrote a book called Freedom Promise.  Her book was motivated by her personal struggle to deal with “disordered eating.”  She said she had a choice, “to stay buried in the dark hole of addictive behaviors, or embrace the light.”  She chose the light.

Mindy explained that disordered eating is when a dieter becomes obsessed with dieting and the need for perfection takes over.  It differs from eating disorders of anorexia, bulimia or non specific eating disorder.  Mindy explains that we are constantly getting conflicting viewpoints from different groups in the dieting industry, a $60 billion industry, based on science as to what the best diet is and that we really need to be told what to eat by them to be succesful

Mindy, as an eating psychology coach, looks to see what, how, when and why we are eating. Things that happen in life effect our relationship with food.  She further discussed how people are creatures of habit and that the habits need to be broken and new healthy eating habits need to be formed.  The best way is to learn about triggers you suffer from in your distorted eating and have strategies to deal with these triggers.  Recovery, according to Mindy is possible when we change the mind and the fear of food.  For recovery you need forgiveness, acceptance and compassion.
One issue that we discussed that is important to me is what message are we giving our kids.  I have teenagers and a daughter, and we need to give the right message to our kids.  We discussed on the show the need to teach our kids, and ourselves, to eat for fuel and not out of emotion.   We also need to talk to our children about inner beauty, paying it forward and focus on how we live and how we have relationships with others.  When my kids eat junk food (my daughter loves her Doritios) I try to be careful in my message to them and have them think of ways to counterbalance the junk food, because after all, the old cliche is still true, we are indeed what we eat.
I often have patients that either tell me that they are never hungry or that they are hungry all the time.  Patients hope that their surgeries will stop them from being hungry and stop their urge to eat.  But, Mindy says you need to ask yourself what are you hungry for? Are you hungry for food or something else that you are yearning for in your life?  Patients often tell me that during the day they are able to stay on track and as soon as it is nighttime they go on binges. (Most likely because during the day we are with others and busy with the day and don’t think about food as much as at night.)  Mindy explains that these binges are caused by triggers and to stop them you have to look within.We talked about my favorite, and America’s favorite cookie, Oreos.  A few months back, I tweeted about the study that came out which compared them to cocaine addiction. (I am quite aware that three cookies has 150 calories and has many things in the ingredients that I can’t pronounce.) . Food companies study how additives affect the brain and these additives in Oreos have been found to have the same affect on the brain as cocaine.  (Not to mention the ingredient list that you need to be a chemist to understand,) Created food  affects neurotransmitters in the brain, but natural food does not.   And we all know real food is the way to go!!!

We had a great discussion about binge eating and how it comes from stress.  When we are stressed we want to check out from the stressful event and sedate ourselves to take away the stress and the pain.  To counteract the stress which can lead to binging, one thing we can do is conscious breathing, which tricks the body into thinking it is relaxed. I do this often to relax myself!!!  And it works!
Another way to stop a binge, according to Mindy, is mindful eating.  Never stand at the pantry and eat out of bags or in front of the freezer eating ice cream from the containers.  If you stop and put the food on a pretty plate or bowl and eat it at the table you will be able to focus on the food, what you are eating and how it feels to eat it.  This makes it a controlled and positive experience and then put it aside.   Mindy also suggests that you need to look at relationships, spirituality, careers and physical activity for pleasure, not only food.  Also don’t practice obsessive punishing exercise, but look to create movement of the body.With weight loss surgery patients, many times there are transfer addictions to drugs, alcohol, or my personal favorite (and yes I do engage in this) retail therapy.  These actions make us feel good and takes away the stress or pain.  It is the same high that you get from food.

Mindy’s book, The Freedom Promise, will be coming out this fall. I know I will be reading it and have some in the office to have my patients read!   She has a website if you want further


13 Apr


Surgery has certainly changed over the years. We used to make big incisions to perform surgery all over the body. These cuts or incisions got dramatically smaller with minimally invasive surgery, which encompasses laparoscopy (operations in the belly), arthroscopy (operations in the joints and endoscopy which includes operations in other parts of the body such as axilla, neck, and the gastrointestinal or bronchial tract.

Since the introduction of minimally invasive surgery, our incisions continue to get smaller (<1cm) as the tools we use to see and to perform the surgery improve.  The field of gastrointestinal endoscopic surgery is just starting to expand the possibilities as the instruments we use start to improve. The endoscope, for those of you have not had the dubious pleasure of ever needing one, is a long flexible tube with a lighted camera on it. The endoscope can also have channels to pass special instruments down to assist with diagnosis, biopsies, brushings or even surgery. Endoscopic surgery of the gastrointestinal tract, in certain cases, can mean no abdominal or chest wall incisions. No cuts! For example, many people have had a polyp removed endoscopically on either upper or lower endoscopy. As the instruments we use in endoscopy improve, larger polyps or tumors  can be removed. This does not mean ALL tumors. It means some tumors or polyps are amenable to an endoscopic resection based on size, depth of tissue involvement and location.

But this post is about endoscopic revision of prior laparoscopic or open surgery. Endoscopic techniques have evolved to allow us to place the same sutures that we use in open and laparoscopic surgery, with the endoscope. We have been looking at reasons that gastric bypass patients regain weight, and patients and studies have documented a loss of restriction, meaning that the gastric bypass patient can eat normal portions again. So hang on- didn’t I make the pouch so small it can only hold 1-2 oz?  Yes, I did. But over time, in some patients, the pouch and the stoma (hookup of new small stomach to the jejunum or intestine- AKA gastrojejunostomy) can dilate or stretch out.

Not all gastric bypass patients regain weight. When a comparison was made between Roux-en-Y gastric bypass patients who did and did not regain weight, stoma size and pouch length were noted to be bigger and longer in those who regained weight1. Other methods to reduce the size of the stoma have been tried. Stomaphyx used anchors instead of sutures and these anchors were not usually full thickness through the stomach tissue. Because the anchors were not full thickness, the reduction in stoma size has not been as durable as we would have liked. I did some procedures using Stomaphyx and was not happy with the results long-term. The ROSE procedure was another endoscopic method to reduce stoma size that currently is not widely available here in the United States. There is a newer device to suture from Apollo Endosurgery that is currently being used in the United States, Latin America and Europe. Some of my international colleagues have published their 12 month data, and it shows that the sutures used to reduce the stoma are durable and that the stoma size remains small at one year out from the endoscopic stoma reduction. Endoscopic suturing of the stoma and pouch results in  20-25% of excess weight loss or 60-65% of weight regained loss. These results have been documented from 3-12 months out.

Patients want to regain the restriction they had right after the Roux-en-Y gastric bypass surgery. Endoscopic reduction of the pouch and stoma will increase the restriction patients’ experience, and their weight loss can be maximized with dietary changes and behavior modification. Endoscopic pouch and stoma reduction should be done in conjunction with the bariatric surgeon and a dietitian well versed in weight loss surgery. This will give the patient the best chance for success. When weight regain happens, patients often feel like they failed. Having contact with the bariatric surgeon and dietitian is the best way to get the motivation, encouragement and support they need for success. Many studies have shown that attending follow up visits after weight loss surgery results in better weight loss.


1. Influence of pouch and stoma size on weight loss after gastric bypass. Helen M. Heneghan, M.D., Panot Yimcharoen, M.D., Stacy A. Brethauer, M.D., Matthew Kroh, M.D., Bipan Chand, M.D. Surgery for Obesity and Related Diseases 8 (2012) 408–415.

where does it stop? yup…organic homemade dog biscuits

7 Mar

So I got a dog. Ok, technically, my daughter wanted a dog, my husband caved , my son was all in, and i was leading a silent cheer for dogdom, trying to stop my face from splitting into two from sheer unadulterated happiness. After all, happiness is a puppy. We went to the ASPCA on 91st in NYC. This is a great place or at least, I think it is a great place. The trainers and workers care and are involved. Our dog was 5.5 months when we got him. He was underweight, and I kept wondering when he would start to forget where he came from and accept our house as home. I, of course, did not want him to get heavy. My dog is part lab and apparently, they are prone to being overweight. He gets no people food but I couldn’t resist the organic treats that are sold in every pet sotre. Seems good right? Organic, wheat -free (Hang on! is that important??), with fruit or honey or peanut butter. I had two dogs growing up, and I gave them Milk Bone dog biscuits after a walk. I figured, if organic is good for my kids, then I should get organic for my pooch.

But do you guys know what gets old real quick? Paying $8.99 for a bag of treats that lasts like two days. I happen to be a baker. Nothing fancy people! Cookies, brownies, pies, quick breads and sometimes a cake come out of the oven. But I have a singular talent to mass produce for school bake sales (well a talent other than my day job;) ), so I thought, I can bake his biscuits! Yup.. a little bit of research, and a biscuit was born. Our dog’s name is Sonny, so I called them Sonny Snax. He loves them. So do the other dogs in the building. I stand a fair chance of getting jumped by the large yellow lab in my building for one of these snax! Sonny has a sensitive stomach and dry skin, so the ensuing recipe is easy on the gi tract and good for the skin!

All products can be organic!

Set the oven for 385 F


1 ripe banana mashed

1/2 cup organic applesauce

2 tbs olive oil

2 tbs molasses

2 tbs organic honey

2 cups rolled oats (not quick cook)

1 1/2 cups organic ground brown rice flour

1/2 cup organic ground flaxseed

mix wet ingredients together, then add dry. I use a small spoon to shape the biscuits and plate them onto silpats and cookie sheets. Bake for ten minutes, flip and bake for 8 minutes more. Makes about 48 snax.
Cool and then refrigerate. I have left them out but they stay refrigerated forn two weeks. The honey and molasses act as a natural preservative. Hope your pooch enjoys.

I have used peanut butter instead of apple sauce or bananas but the this mix is i think a tasty biscuit. Yes I sample them!


laparoscopic lower esophageal sphincter augmentation using LINX magnets

7 Mar

Esophageal Sphincter Augmentation for the Treatment of GERD

There’s a new technique to fight GERD, heartburn or reflux. These symptoms occur because the lower end of the esophagus, the lower esophageal sphincter, is not tight and not creating a high pressure zone.

The esophageal sphincter, in patients without GERD, creates a high pressure zone so that food and fluid that is in the stomach doesn’t reflux back into the esophagus. When food refluxes from the stomach, so usually does acid. The reflux gives patients the sensation of burning which occurs behind the sternum- hence, heartburn. Patients also can feel the food reflux up into their chest and sometimes note a sour brash or acrid taste in their mouths. Some patients have a cough or throat pain.

Many people self medicate for these symptoms, including taking TUMS, Mylanta and over the counter acid reduction meds like Pepcid AC or Prilosec OTC. Other people will see their doctor and get a prescription for an acid reducing medication like full strength Prilosec or Nexium. Some patients may also need an upper endoscopy, where a surgeon or a gastroenterologist puts a long tube down the throat that is also a camera, known as an endoscope. This helps look at the inside of the Esophagus, Stomach and first part of the intestine, the Duodenum, and so the procedure is also known as EGD (Esophagogastroduodenoscopy). An EGD helps identify inflammation like esophagitis or gastritis as well as ulcers and hiatal hernia.

There is a naturally occurring hole in our diaphragm called the esophageal hiatus. This hiatus allows the esophagus to pass thru the chest and then into the abdomen. If that hiatus is wider than it should be, the lower esophagus and stomach can move through the diaphragm and into the chest. How much stomach goes into the chest determines the size of the hiatal hernia. But know this, when you have a hiatal hernia, there is no high pressure zone for your lower esophagus and you will have GERD.

There are several surgical treatments for GERD as well as endoscopic treatments. All of the treatments involve a fundoplication, meaning that a valve or flap is created to make a high pressure zone between the stomach and the esophagus. The endoscopic treatments work in patients that don’t have a hiatal hernia. There are times that I will do a hybrid procedure with a gastroenterologist where I fix a hiatal hernia, and the gastroenterologist does the endoscopic fundoplication. Other times, I will do a surgical fundoplication where I fix the hiatal hernia and wrap the stomach around the lower esophagus to create a flap valve. If the wrap goes all the way around the esophagus, then it is considered a Nissen, and if it goes only ¾ of the way, it is a Toupet.

This new technique to augment the lower esophageal sphincter involves magnets. Yes, you read correctly, Magnets! The idea is to create a bracelet on the lower esophagus that sits above the stomach that can open and close with each swallow creating a high pressure zone. As food or liquids come down the esophagus, the pressure generated by the esophagus as it squeezes the food down, opens the magnetic bracelet. As the food passes thru into the stomach, the magnets do what magnets do and attract each other back to recreate the high pressure zone.

The company that makes the device is called Torax, and the device is called LINX. The magnets are linked together in a way that they can open and close. The device has been tested and approved by the FDA in a rigorous process with over three years of study. The procedure is safe and the risks include potential for bleeding and infection as is the case for any fundoplication. The magnets are placed laparoscopically so the incisions are very small, and the procedure takes about an hour. Patients are discharged the same day, and unlike with fundoplication procedures, they can eat a normal diet immediately. 90% of patients who have had this procedure out to three years have improvement or resolution of their GERD symptoms.

sleeve gastrectomy or vertical sleeve gastrectomy

13 Jan

Here’s part of an article I wrote for our newsletter

Sleeve Gastrectomy: The New Kid on the Block
Maybe the title is a little misleading. Sleeve gastrectomy or vertical sleeve gastrectomy has been around for weight loss since 2001. Sleeve gastrectomy involves removing approximately 70% of the stomach and leaving the stomach in the shape of a banana, and is usually done laparoscopically or with small incisions. It was a procedure originally designed for people who weighed over 400 lbs and were considered too high risk to have a gastric bypass or duodenal switch because it would take a long time in the operating room to perform. So, taking out part of the stomach is a shorter operation, and the idea was that it would be safer to remove the stomach as a first stage of weight loss surgery. We hoped that the patients would lose at least 100 pounds, and then we would bring them back to surgery to bypass their intestines. What we found was interesting! When vertical sleeve gastrectomy patients were called to come back for the second stage of their weight loss operation, the intestinal bypass, they refused! Patients routinely lost over a hundred pounds and would not consider a second stage until their weight loss leveled off. So, that started all of us surgeons thinking, “What if sleeve gastrectomy could be a stand alone operation for weight loss, like gastric banding and gastric bypass?”
Sleeve gastrectomy started to increase around the country slowly. Our numbers have increased significantly since we got an insurance or CPT code for sleeve gastrectomy in January 2010. Most insurance companies cover sleeve gastrectomy if weight loss surgery is a covered procedure under your plan. So why is sleeve gastrectomy the new kid on the block? We finally have five year weight loss data for the sleeve so we can measure it up against the other weight loss procedures.
The weight loss for sleeve gastrectomy is somewhere between the results for gastric banding and gastric bypass. As we do more sleeve gastrectomies around the country and the world, different hormonal aspects of the operation are becoming clearer. Sleeve gastrectomy affects hunger because we remove the part of the stomach that makes ghrelin, a hormone that is elevated when people are hungry. We find that hunger in our sleeve patients is reduced and stays reduced long term. The operation also makes people eat a lot less because a lot of the stomach is removed. Most of the weight loss with sleeve occurs in the first year. The follow up with your surgeon and dietitian is crucial for ongoing success. There is another hormone, GLP 1, which is important in improving Type 2 Diabetes Mellitus. With sleeve gastrectomy, patients can expect a rise in this hormone with a resulting drop in their blood sugar and improvement or remission of their diabetes. With weight loss, Type 1 or adolescent diabetics will also see an improvement in their blood sugar and a reduction in their insulin usage.
Since sleeve gastrectomy involves removal of a large part of the stomach, there is potential for leaks to occur. A leak is when the staple line used to make the stomach smaller is not watertight. Other procedures may be necessary to control a leak. Leak rates for sleeve gastrectomy are approximately 1%. Weight regain is also possible with the sleeve and approximately 1/15 patients will require a reoperation for inadequate weight loss or weight regain. Find a surgeon well versed with weight loss surgery and the possible complications as well as the best treatments of weight regain if it occurs. Long-term with a sleeve, complications like bowel obstruction that can happen with gastric bypass are not common. I encourage all weight loss surgery patients to take a multivitamin and return for the prescribed follow-up. Follow up is approximately 5-7 visits the first year and 2-3 the second year. I then see patients annually. I know support groups are a great way to stay on track on your weight loss journey so definitely commit to going.


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