drmarinakurian

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!

Frequently Asked Balloon Questions:

Dr. Marina Kurian is the first surgeon in the United States to be trained on the Orbera balloon. She is excited about adding the balloon to the armamentarium of weight loss methods that she offers. She also feels the Orbera is a great way to get people back on track for their life of health and wellbeing and off the path of obesity.

What is the balloon made of? Can I be allergic?

The balloon is made of silicone and it is very soft even when filled with saline. It is extremely unlikely that you can be allergic to it.

What is the expected weight loss?

With the gastric balloon, expect a weight loss of 30% of excess weight on average. Some people lose more and some people lose less. Speak with Dr Kurian regarding what you can expect.

What are some of the side effects?

Within a day or two of balloon placement, you can experience some nausea. Dr. Kurian will have certain medications prescribed for you to minimize this effect. Your appetite will be diminished. You may also experience a spasm type pain in your upper abdomen. Dr. Kurian will give you a medication to counter this symptom. Your diet will be liquids for the first week and then pureed and soft foods to ease into having the balloon in your stomach. Dr Kurian and her dietitian will have a protocol for you to follow.

Why do I have to have the balloon removed?

The balloon is a foreign body and cannot stay in your stomach forever. The studies show that after 6 months, the chance of infection increases substantially, putting you at risk for infection. The cost of the whole program includes balloon removal and the anesthesia associated with the second procedure. You CAN NOT keep a balloon for longer than 6 months.

Will I gain weight back once the balloon is out?

Dr. Kurian’s gastric balloon program for obesity management includes a year of dietary care. Following a dietary regimen as well as behavior modification with a more active lifestyle is necessary for longterm maintenance of weight lost. If you fall back into old habits or poor eating behavior, the weight can come back.

What kind of anesthesia will I need for the procedure?

For the initial endoscopy and placement of the balloon, intravenous sedation will be administered by an anesthesia professional. For the balloon removal, a short general anesthesia is used. Both placement and removal are generally under 30 minutes. You will need someone to take you home after placement and removal of the balloon.

Call Dr. Kurian for an appointment at 855-587-4261 to take the next step! Be in control of your weight with expert help. The Orbera or intragastric balloon is a novel way for you to get rid of that excess weight and live the healthy life you deserve to lead.

Click on the links below to see recent articles and press releases for Dr. Kurian:

http://www.surgicalproductsmag.com/articles/2015/08/gastric-balloons-what-history-taught-us-and-how-they-work

From SAGES:

FDA Approval of ReShape™ Dual Balloon Marks Significant Step for the Weight Loss Program in Helping at Risk Group of Patients Obesity is on the rise and is a worldwide epidemic. A recent Lancet study noted that the chance of an obese person becoming normal weight is less than .5%.  Currently in the United States, the obese population outnumbers the overweight population. Bariatric surgery helps patients with severe obesity in terms of weight loss, reduction in severity and number of comorbid conditions. This week the U.S. Food and Drug Administration approved the ReShape™ Integrated Dual Balloon System (ReShape™ Dual Balloon) to treat obesity without the need for invasive surgery. “There are few treatments available for obese patients and the FDA approval of the ReShape™ Dual Balloon significantly increases the armamentarium of weight loss programs in helping this at risk group of patients,” said Dr. Marina Kurian, Chair of SAGES Endoscopic Bariatric Task Force and Bariatric Surgeon at New York University Langone Medical Center. Intragastric balloons are a non-surgical treatment option for patients, different than current therapies, but should be offered in a comprehensive bariatric care center to promote the best outcomes.  In an outpatient setting, interventional endoscopists will be able to place this non-surgical device. Many patients may receive this as a primary treatment for obesity and others may use this temporarily as a bridge to safer laparoscopic surgery. The success of the gastric balloon is impacted by patient follow up and dietary guidance. The intragastric balloon is a six month intervention at which point it is removed. Patients remain in a structured dietary program for a year so that weight lost is maintained. The balloon has been approved for patients with a body mass index (BMI) of 30 to 40 with unsuccessful attempts at weight loss and should be placed for obese patients enrolled in a structured weight loss program. According to Dr. Matthew Kroh, co-chair of SAGES Endoscopic Bariatric Task Force and Director of Surgical Endoscopy at the Cleveland Clinic, “The introduction of intragastric balloon therapy for Americans will allow patients access to a minimally invasive non-surgical approach to treat obesity and weight related disease. Overall, the FDA approval of the balloon is an important aid in the battle to stem the tide of obesity.” Additional information on the FDA approval of the ReShape™ Dual Balloon can be found at http://www.fda.gov/NewsEvents/N FDA Approves Non-Surgical Solution ORBERA™ To Assist Patients With Weight Loss The U.S. Food and Drug Administration has approved the ORBERA™ Intragastric Balloon to assist adult patients suffering from obesity in losing and maintaining weight loss. Obesity affects more than 78.6 million U.S. adults and is one of the leading causes of preventable deaths in the U.S. In 2008, an estimated $147 billion was spent in medical costs for obesity. If obesity trends continue, it’s estimated that related medical costs could rise by $43 to $66 billion each year in the U.S. by 2030.   “In light of the obesity epidemic, it’s promising to see such innovative weight loss solutions like ORBERA™ being made available to patients suffering from obesity who are not appropriate for or considering invasive surgery,” said Dr. Marina Kurian, Chair of SAGES Endoscopic Bariatric Task Force and Bariatric Surgeon at New York University Langone Medical Center.   ORBERA™ is an incision-less, non-surgical weight loss solution designed for adult patients suffering from obesity, but for whom diet and exercise or pharmaceutical interventions have not worked. In a non-surgical (endoscopic) procedure done under a mild sedative, the thin and deflated ORBERA™ balloon is placed into the stomach. It is then filled with saline until it’s about the size of a grapefruit. The procedure typically takes about 20 to 30 minutes and the patient can generally go home the same day. At six months, through another non-surgical procedure done under a mild sedative, the ORBERA™ balloon is deflated and then removed.   “Obesity is a chronic disease and the development of new, minimally invasive solutions, can possibly help stem this epidemic by treating patients before their disease progresses and requires further invasive procedures,” said Dr. Matthew Kroh, co-chair of SAGES Endoscopic Bariatric Task Force and Director of Surgical Endoscopy at the Cleveland Clinic. “Though intragastric balloons offer a non-surgical treatment option for patients, different than current therapies, they should always be offered in a comprehensive bariatric care center with proper patient follow up and dietary guidance to promote the best outcomes,” added Dr. Kroh. Interventional endoscopists can place ORBERA™ in an outpatient setting. Many patients may receive this as a primary treatment for obesity while others may use this temporarily as a bridge to safer laparoscopic surgery. The intragastric balloon is a six month intervention at which point it is removed. Patients remain in a structured dietary program for a year so that weight lost is maintained. The device has been approved for patients with a body mass index (BMI) of 30-40 with unsuccessful attempts at weight loss and should be placed for obese patients enrolled in a structured weight loss program. For additional information regarding ORBERA™, please visit www.ORBERA.com. SAGES has been at the forefront of best practices in endoscopic and laparoscopic surgery by researching, developing and disseminating the guidelines and training for standards of practice in surgical procedures. SAGES Guidelines for Clinical Application of Laparoscopic Bariatric Surgery, were issued in 2008 and are a series of systematically developed statements to assist physicians’ and patients’ decisions about the appropriate use of laparoscopic surgery for obesity. Guidelines are available at http://www.sages.org/publications/guidelines/guidelines-for-clinical-application-of-laparoscopic-bariatric-surgery. About SAGES The mission of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) is to improve quality patient care through education, research, innovation and leadership, principally in gastrointestinal and endoscopic surgery. SAGES is a leading surgical society, representing a worldwide community of over 6,000 surgeons that can bring minimal access surgery, endoscopy and emerging techniques to patients worldwide. The organization sets the clinical and educational guidelines on standards of practice in various procedures, critical to enhancing patient safety and health.

Something new in the treatment and prevention of obesity? Intragastric Balloons

The FDA has approved two new devices for weight loss. The devices are known as the Orbera and Reshape Dual Balloon or the intragastric balloons.

Balloons? Weight Loss? …Yes!

A soft, silicone balloon(s) is placed into the stomach endoscopically and then filled with sterile saline. Basically, the balloon takes up space, and you can’t eat as much food.

Endoscopy is something that is done commonly to evaluate the inside of the stomach. A small, thin tube with a camera (endoscope) on the end is placed into the mouth and down the esophagus into the stomach. Once the stomach is evaluated, the endoscope is pulled out, and the balloon is passed down into the stomach. The endoscope is passed again to check the position of the balloon, and then the balloon is inflated with sterile saline.

The balloon can only stay in the stomach for 6 months. After that, there is a risk of infection so it is important to get the balloon out by 6 months. During those six months, you are on a supervised diet, with scheduled meetings with a dietitian. The nutritional care is for a year with insertion of the balloon, so this will continue for the six months after the balloon is removed. Patients can expect to see an average of 30% of excess weight loss tho results can vary.

By staying on a healthy eating pattern and exercising (because the balloon won’t stop you from exercising), you can expect to keep the weight off for some time.

There is some nausea when the balloon is initially placed, and with medication, this nausea resolves. Then the stomach and you get used to the balloon, and continue on the journey of weight loss.

The FDA has approved the balloon for BMI 30-40. Make an appointment to discuss the balloon even if you feel you may be outside of this BMI range.

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!

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 informationwww.thefreedompromise.com.

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.

References

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.

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!

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.