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.