SAGES Meeting 2017: GERD and Obesity

The annual meeting for SAGES (Society of Gastrointestinal and Endoscopic Surgeons) was in Houston this year. I have attended most of the bariatric sessions and I have pleasantly surprised. Most weight loss surgery lectures were well presented and quite relevant to my practice at Houston Weight Loss Surgery Center. The dominant theme this year was related to GERD management in obese patients. The effect of sleeve gastrectomy on pre-existing and de novo GERD was particularly debated on more than one occasion. Is GERD a contraindication for sleeve gastrectomy? Does sleeve gastrectomy result in de novo GERD? Two questions that remain unanswered.

According to one presenter, obese patients with symptomatic GERD should only be offered gastric bypass surgery and never sleeve gastrectomy. According to this presenter, around 20% of sleeve gastrectomy patients will develop de novo GERD. Couple of years ago, I used to believe in these assumptions. Recently, however, I have realized that sleeve gastrectomy effect on GERD is much more complicated than these assumptions and deserves deeper study and thorough analysis.

Gastric anatomy and physiology including gastric emptying and its effect on GERD, obesity and gastroparesis remain poorly understood. When weight loss surgeons started performing sleeve gastrectomy several years ago, the debate concentrated on bougie size. How tight can the sleeve be made to achieve the best weight loss? The assumption that the smaller the volume the better weight loss has dominated bariatric surgery for many years. With this guiding principle in mind, sleeve gastrectomy has evolved over a short period of time into a mutilating procedure. Around 90% of the stomach was resected including the gastric antrum to achieve the smallest possible volume. The delicate and complex gastric anatomy was completely overlooked and the stomach was straightened into a narrow and stiff tube along a small size bougie. The incisura angularis was completely obliterated resulting in most cases in a functional obstruction. The result was a high-pressure system that favored GERD development or worsened pre-existing GERD especially in the presence of a hiatal hernia.

The art of gastric sleeve surgery requires antrum and incisura angularis preservation, aggressive gastric fundus resection and proper hiatal hernia repair. Following these steps, maximizes weight loss and minimizes GERD. Our results at Houston Weight Loss Surgery Center and Houston Heartburn and reflux Center clearly indicate that gastric sleeve surgery is as good as Nissen fundoplication for acid reflux control. Indeed, we recommend hiatal hernia repair and sleeve gastrectomy for obese patients presenting with GERD as an effective cure for acid reflux. There is no need to perform a gastric bypass on a GERD patient with a BMI of 32 and no other obesity related co-morbidities. The key to gastric sleeve success and patient satisfaction is proper sleeve gastrectomy surgery technique.

The 12th Annual Bariatric Summit (Austin Texas, 2015 )

Last weekend I had the opportunity to attend the Bariatric Summit for 2015 in Austin, TX. It was my first time in Austin ever since I have moved to Houston to establish my current practice Houston Weight Loss Surgery Center. Besides enjoying the great weather in Austin I found the meeting to be quite organized and informative. The meeting started with case scenarios touching on various subjects and challenges in bariatric surgery. The next session was about the preoperative workup for bariatric patients at the Brigham and Women’s Hospital where the meeting chair practices. This was followed by a session on revisional bariatric surgery and I am going to devote a blog in the future to discuss this very important topic. The day then ended with several presentations on the future of bariatric surgery. Single Anastomosis Duodenal Ileostomy, Gastric Balloon, and Vagal Nerve Blocking and Neuro-modulation were debated as emerging obesity treatments. These are very controversial topics in our field and for this blog I am going to stick to the obvious and most important aspect of bariatric surgery: Nutrition before and after weight loss surgery.

Patient readiness for bariatric surgery from a nutritional point of view is, in my opinion, one of the most important predictor of long-term success after bariatric surgery. It is not only important to educate our patients about healthy eating but also to engage them. The rules of engagement, at Houston Weight Loss Surgery Center, start with clear, concise and relevant dietary recommendations:

  1. Stop Junk food consumption
  2. Stop eating out
  3. Completely empty your house from junk food snacks
  4. Don’t skip breakfast
  5. Start home cooking

According to Wikipedia “Junk food is a pejorative term for food containing high amount of calories from sugar or fat with little protein, vitamins or minerals. Use of the term implies that a particular food has little nutritional value and contains excessive fatsugar, salt, and calories. Junk food can also refer to high protein food containing large amounts of meat prepared with, for example, too much unhealthy saturated fat; many hamburger outlets, fried chicken outlets and the like supply food considered junk food”. We clearly explain to our bariatric patients that junk food and weight loss surgery don’t go hand in hand. Since most restaurant food is junk food, there is no other alternative but to stop eating out and start cooking at home. People think that junk food is limited to fast food restaurant chains. As one patient once told me: “ I don’t eat junk food at all. I do however eat out at least twice a week at Olive Garden”. Olive Garden and other chain restaurants as well as high-end restaurants have never served and will never serve you home cooking quality food. “Even in the finest restaurants, restaurant food, while delicious and deserving of its place as entertainment and theater, is really not the best food at all. It’s over-sauced and over-salted and over-rich, because the only thing restaurant chefs have to worry about is that the food tastes exquisite on the table. They don’t have to worry about whether you should eat less salt and fat or eat more vegetables or if you are consuming trans fats or saturated fat or petroleum… What you pay for in most restaurants is for the transformation from ordinary into good or exquisite. And one of the ways that food is transformed is through copious amounts of butter, salt, and stocks”, said Sara Jenkins, a restaurateur herself. THERE IS NO SUBSTITUTE TO HOME COOKING. Home cooking, in my opinion, remains the best safe guard against weight regain after bariatric surgery. When a patient tells me that he or she started cooking at home I know that they are going to do very well. For Bariatric surgery does not work unless we resolve the important factor that contributes to obesity in the first place: food quality and eating habits. When you cook at home you control your food quality. You are not going to use preservatives, flavor enhancers, margarine, excess butter and salt. When you cook at home you are not going to supersize your meals and you are not going to prepare decadent deserts every night. Finally, when you cook at home you are not going to graze on food throughout the day for two reasons. First, assuming you have emptied your house from all processed and packaged food snacks, you are not going to prepare snacks yourself at least not on a daily basis and hence there is nothing to snack on. Second, you don’t need to snack on anything and you wont have the urge to munch on food continuously because home cooking is balanced, nutritious and filling. For all these reasons, the staff at Houston Weight Loss Surgery Center, urge you to invest your time and efforts in home cooking prior to committing to weight loss surgery. After all cooking is not that difficult.

Here is chef Jenkins again with a practical advice on how to start cooking yourself: “If you really want to put great food on the table day in and day out, restaurants are not really what you want to emulate. What you need is a few techniques and a few standards and eventually you will have the ability to improvise and adapt. Learn a couple of recipes well and then build on them. I’m a huge fan of broiling a fish filet or even a fish steak. It’s quick, it’s easy, it’s healthy, and you can change it endlessly depending on what you season it with”. She goes on to add: “I like to have a couple of different dried grains and beans in my pantry, because you can cook up lentils so quickly and mix them with olive oil and herbs, and have a simple and quick dish anyone can make in 20 minutes. I keep a couple of great cast-iron pans, and because they hold and transmit heat so well I can pan-sear things as diverse as shrimp, chicken breast, or lamb steaks. On weekends I am more likely to make a slightly more complicated braise or stew that can get extended later in the week with some beans or grains.”