# Houston Weight Loss Surgery Center

> Elias Darido, MD, FACS

> Contact: matt+sleeve@firesuite.net

### Posts

#### A Bariatric Surgeon Perspective on Keto Diet
3 months after sleeve gastrectomy, a patient of mine lost 65 pounds and so did her husband on whom I did not operate. My patient was on a typical post gastric sleeve diet consuming 900 calories a day with excellent appetite control. Her husband was similarly enjoying great satiety while consuming a high fat diet amounting to at least 2500 calories a day. He was following a ketogenic diet also known as keto diet. If you haven’t tried keto diet yet, you have most likely heard or read about it somewhere over the past 6 months. Keto diet that involves stopping carbohydrates and replacing them with natural fats like olive oil, avocado, grass fed meat and butter is quite a la mode these days. Excellent early weight loss results, supported by a number of studies, are one of the reasons behind its widespread acceptance.

Personally, I am not a fan of fad diets for quick weight loss purposes. I am a proponent of durable weight loss solutions like bariatric surgery. Bariatric surgery decreases appetite, reverses insulin resistance and decreases blood glucose. Interestingly, a ketogenic diet does the same. Bariatric surgery is effective and durable because it changes the interaction between ingested carbohydrates and gastro-intestinal tract. As a result of this new interaction, a number of gut hormone secretion, like GLP-1, is altered resulting in increased satiety and improved postprandial glucose metabolism. Ketogenic diet achieves the same purpose by significantly restricting carbohydrate intake, hence, bypassing a “faulty” glucose processing physiology. Let me explain.

Our modern, heavy on sugar and processed carbohydrates, diet has disrupted the delicate physiology of glucose metabolism. In the setting of a sedentary lifestyle, excessive sugar intake resulted in insulin resistance that favored fat accumulation leading to obesity. Bariatric surgery like sleeve gastrectomy, gastric bypass and duodenal switch is an effective weight loss tool because it alters hormones like GLP-1.  GLP-1 plays a central role in glucose metabolism, satiety control and weight loss. Keto diet is similarly effective through a different mechanism of action. By replacing carbohydrates with fat, GLP-1 secretion is no longer needed to metabolize glucose. Indeed, a high fat diet impairs L cell secretion of GLP-1 because GLP-1 is not required in the setting of a high fat diet. Keto diet bypasses impaired GLP-1 secretion and bariatric surgery restores GLP-1 secretion. Both approaches result in significant and durable weight loss. Weight loss is durable with a keto diet because unlike a low-calorie diet, ketosis is associated with a high level of satiety. The brain is receiving plenty of energy in the form of ketones and does not induce an energy conservation mode. On the contrary, keto diet promotes breakdown of excess stored fat.

To summarize, in a state of insulin resistance, replacing glucose with fat to become the primary source of energy seems to be a good solution for weight loss. Ketosis like bariatric surgery achieves a state of low insulin, low glucose blood levels and increased satiety. In future blogs. I will go in more details about how to start keto diet, how to maintain weight loss on keto diet and I will share with you my personal experience with ketogenic diet.

#### A New FDA Warning Regarding Gastric Balloons
The FDA has recently issued an alert about five reported deaths that have occurred in patients within 30 days following gastric balloon placement. Four reports involve the Orbera Intragastric Balloon SystemTM, manufactured by Apollo EndoSurgery, and one report involves the ReShape Integrated Dual Balloon SystemTM, manufactured by ReShape Medical Inc. 3 patients died one to three days after balloon placement. The intragastric balloon system has been recently approved by the FDA for weight loss in patients whose BMI is between 30 and 40. Both companies Orbera and Reshape have advertised the gastric balloon as “weight loss surgery without the surgery” and as a safe solution for weight loss. Recent reports have surfaced about balloon induced pancreatitis and spontaneous balloon over-inflation. Both conditions may lead to serious consequences. Gastric distention from balloon spontaneous over-inflation can result in aspiration and possible death.

I should mention that the exact cause of death in all 5 reports has not yet been determined, and a cause effect relation between intragastric balloon and death has not yet been established. We will continue to monitor FDA input in the coming few weeks and keep our patients updated. Houston weight loss surgery center does not endorse intragastric balloon as an effective weight loss solution. Gastric balloon procedure is a purely restrictive technique without any apparent metabolic effect. We have learned over the past few years that successful weight loss surgery like sleeve gastrectomy alters several gastro-intestinal neuro-hormonal signals leading to durable weight loss. We hope more research is focused on the metabolic effects and mechanism of action of gastric bypass and sleeve gastrectomy. Only by understanding the mechanism of action of metabolic surgery we can develop newer, safer and more effective solutions for weight loss.

#### A New Science On The Horizon: Your Gut Bacteria
I read with great interest the many articles being published on gut bacteria and their effect on health. Hardly any day passes by without coming across a new research study about this fascinating new science. Trillions of bacteria live in the large intestine (colon) and they seem to have a major effect on many aspects of our health. New research is revealing that these bacteria also called gut flora secrete a variety of substances that affect the brain, immune system, metabolism and diabetes, as well as your heart. Largely ignored in the past, we are only beginning to understand their role. Gut bacteria play an important role in maintaining the integrity of the intestinal wall and preventing the so called “leaky gut syndrome” which is believed to be responsible for many inflammatory diseases including coronary artery disease. Gut bacteria secrete a number of substances that are absorbed into the blood stream and affect distant organs like the brain. Serotonin is a well-known neurotransmitter in the brain but 90 % of body serotonin is secreted in the gut. Studies have shown that germ free mice (mice with no bacteria living in their intestines) produce 60% less serotonin than those with regular gut bacteria. Low serotonin level in the brain is associated with anxiety and depression. Indeed, studies in a timid strain of mice, treated with antibiotics to change their gut bacteria composition, show a dramatic change in their behavior. In another experiment, transferring bacteria from timid strain mice into the gut of normally active mice changes the latter into more passive animals. Many other experiments mainly in mice prove that bacteria living in the colon affect brain function including behavior and mood. Interestingly, gut bacteria alter more than just your mood; they have a role in weight control. Bacteria from an obese mouse injected in the colon of a regular mouse lead to weight gain. Gut bacteria from obese individuals compared to lean ones show less diversity and predominance of one variety called Firmicutes. Gastric bypass in mice and humans lead to changes in gut bacteria that are associated with weight loss. The mechanisms behind these observations are still unclear. One thing for sure, however, maintaining a healthy gut flora seems to prevent a plethora of diseases and mental disorders.
How to Protect Healthy Intestinal Bacteria?
Like any living organism, bacteria need a suitable environment to thrive. Besides avoiding unnecessary antibiotics that decimate your bacterial flora, consuming a high fiber, plant based diet promote a healthy and diverse gut microbiome. According to Michael Pollan “With our diet of swiftly absorbed sugars and fats, we’re eating for one [kind of microbe] and depriving the trillion of the food they like best: complex carbohydrates and fermentable plant fibers. If you want to feed your gut bacteria, you need to eat a wide variety of fruits, vegetables, nuts and whole grains. Intestinal bacteria need fiber to thrive and Houstonians are not eating enough fiber in their diet. Take control of your life and minimize the consumption of processed food rich in salt and sugar and completely devoid of fiber. Let food be your medicine and rid yourself of obesity, heart disease and diabetes.

#### A Stomach Road or ‘‘Magenstrasse’’ for Weight Loss
In 1908, Waldeyer described a longitudinal fold along the lesser curvature of the stomach that he called Magenstrasse. The Magenstrasse is a gastric canal that carries liquid and solid food particles from the cardia, along the lesser curvature and down to the pylorus very quickly. A sample of ingested food is emptied along the Magenstrasse before the stomach is filled. This early gush of food into the duodenum generates several neuro-hormonal signals that prepare the intestines and other organs for the upcoming meal. Glucagon like peptide or GLP-1 is one of those signals and it is probably the most studied intestinal hormone. GLP-1 is secreted by L cells that are mainly located in the distal gut. GLP-1 stimulates post-prandial insulin secretion and inhibits gastric emptying. GLP-1 plays a central role in glucose homeostasis. GLP-1 secretion peaks shortly after a meal is ingested and prior to any significant gastric emptying. It is logical to assume that GLP-1 secretion depends on food delivery into the duodenum via the Magenstrasse pathway. Therefore, loss of the Magenstrasse emptying pathway leads to deficient GLP-1 and other neuro-hormone secretion leading to elevated post-prandial blood and abnormal insulin secretion. Indeed, one of the earliest signs of type 2 diabetes is loss of the post-prandial GLP-1 peak secretion. 

Sleeve gastrectomy restores the Magenstrasse pathway of gastric emptying. In fact, during sleeve gastrectomy, most of the stomach is resected preserving the longitudinal fold that was described in 1908 by Waldeyer. Sleeve gastrectomy increases gastric emptying. Gastric sleeve surgery results in post-prandial GLP-1 increase and blood glucose improvement. Currently, there is plenty of evidence in the literature that type 2 diabetes and obesity, like gastroparesis, are gastrointestinal motility disorders. Weight loss surgery in the form of sleeve gastrectomy restores normal gastric emptying patterns, like the Magentrasse, resulting in diabetes resolution and weight loss. 

Gastric emptying is a complex process that is a carefully regulated. Neuro-hormonal regulatory mechanisms synchronize the emptying process to achieve optimal nutrient digestion and absorption. Ghrelin is a potent stimulator of gastric contractions and emptying, and GLP-I profoundly inhibits this emptying process. Numerous other signals participate in this process and are yet to be fully elucidated. The sharp rise and fall of these hormones, after food intake, control one of the most important aspects of life: energy metabolism. Unless we understand the interaction between foregut and ingested food, we cannot understand diseases like obesity, type 2 diabetes and gastroparesis, nor can we develop better, safer and less invasive treatment modalities. In my next blog, I will revisit the subject of gastric fundus invagination and its effect on the Magenstrasse pathway of emptying.

#### Acid Reflux Disease In Patients presenting For Bariatric Surgery: A Whole Different Ballgame
I read with great interest the articles “Esophageal abnormalities in morbidly obese adult patients” and “Frequency of Abnormal Esophageal Acid Exposure In Patients Eligible For Bariatric Surgery”. Both studies were published in SOARD (Surgery for Obesity and Related Disorders). The authors conducted a thorough study on 224 (first study) and 88 (second study), overweight patients preparing for weight loss surgery. All patients were examined and a detailed acid reflux related symptom evaluation was performed. In addition, each patient received a complete objective esophageal evaluation including:

 	Upper endoscopy
 	Esophageal manometry
 	Ambulatory esophageal pH monitoring.

The results of the first study showed that heartburn (51%) and regurgitation (29%) were the most common acid reflux disease related symptoms. Hiatal hernia was found in 12%, and inflammation of esophagus lining was present in 17%. 33% had abnormal esophageal manometry with a low pressure lower esophageal sphincter as the most common finding. Twenty-four hour esophageal acid level monitoring was abnormal in 54% of the cases.

The authors did not find a correlation between the degree of obesity and the severity of GERD related symptoms or esophageal function test results.

Similarly, the second study showed that 65% of patients had an elevated esophageal acid exposure and 46% had weak lower esophageal sphincter pressure. Only 20% of the patients showed an abnormal endoscopic finding like a hiatal hernia.

The authors also show that GERD symptoms in overweight patients do not predict severity of disease. In other words, you can can have severe symptoms and mild reflux and mild symptoms. Or, you can have mild symptoms and severe acid reflux disease.

Furthermore, esophageal acid exposure was elevated in more than 50 % of patients presenting for bariatric surgery in both studies. At the same time, the incidence of a hiatal hernia detected on upper endoscopy is much lower. This is due to:

 	Acid reflux can occur in obese patients before a hiatal hernia develops.
 	Hiatal hernia can be missed on upper endoscopy because fat accumulation obliterates the hiatal opening.

 	Consequently, a bariatric surgeon may falsely assume that a concomitant hiatal hernia repair during gastric sleeve surgery is not warranted.



At Houston Weight Loss Surgery Center, almost every gastric sleeve surgery we perform is associated with a concomitant hiatal hernia repair. Obesity and GERD are inter-related diseases. Fixing one while ignoring the latter, leads to worsening or new onset acid reflux after sleeve gastrectomy. A good hiatal hernia repair along with a properly performed and well contoured gastric sleeve surgery reliable eliminates and prevents acid reflux development.

 

#### Acid Reflux, Sleeve Gastrectomy, Gastric Bypass
I’ve had gastric sleeve surgery and had acid reflux so bad my doctor did gastric bypass surgery. Now I have acid reflux worse. Can I be fixed? Or do I just have to live with it the rest of my life? Sincerely, Dwight

Dear Dwight,

At Houston Heartburn and Reflux Center, we believe that no one has to live with acid reflux disease. Acid reflux is a debilitating medical problem that affects every aspect of your life. Fortunately, we have reliable, effective and safe solutions for acid reflux. For instance, hiatal hernia repair with sleeve gastrectomy is a great solution for an overweight patient with acid reflux disease. An important caveat to this statement is that patient must properly worked up for GERD and surgery must be properly performed. GERD work up is crucial to confirm the diagnosis of reflux, stage the disease and accordingly tailor the best treatment option to the particular condition. GERD work up includes basic tests like upper endoscopy and ambulatory pH testing. You may feel heartburn, a burning sensation behind the breast bone, but you may not have acid reflux disease. This is typically found in patients with a hypersensitive esophagus. Neither a sleeve nor gastric bypass will help you eliminate the sensation of heartburn in this case. You may have an esophageal motility problem like achalasia or a gastric emptying issue like gastroparesis. Both conditions limit the effectiveness of gastric bypass in alleviating your symptoms. In addition to proper workup and patient selection, anti-reflux surgery must be perfectly executed to stop reflux. This is particularly relevant to gastric sleeve surgery. Gastric sleeve must be properly contoured with no narrowing or twisting. Hiatal hernia must be completely reduced, and distal esophagus fully mobilized. Short of perfectly executing these steps, acid reflux is not likely to resolve.

My recommendations for you is to be properly tested for GERD using upper endoscopy, ambulatory pH testing, esophageal manometry and upper GI contrast study. Acid reflux in the setting of gastric bypass was covered in previous blogs and can be fixed. Hope this helps.

Sincerely,
Dr. Darido

#### Adjustable Gastric Band Reoperation Cost
I read with great interest this large retrospective study, titled “Reoperation and Medicare Expenditures After Laparoscopic Gastric Band Surgery” that was recently published in JAMA surgery. The authors analyzed the outcomes of 25 042 obese Medicare patients who underwent gastric band surgery between 2006 and 2013. They found that 20% of analyzed patients underwent gastric band related revision procedure at a staggering cost of 224 million dollars. Of note, during the study period, Medicare paid $470 million for laparoscopic gastric band–associated procedures. Reoperations included band removal, band replacement or revision to a different bariatric procedure like gastric bypass or sleeve gastrectomy. 80% of the reoperations were elective suggesting that weight loss failure or development of severe GERD rather than acute band slippage were the main cause for revision.

The study highlights the long-term complication rate of adjustable gastric banding and associated cost. The results are no surprise to the majority of bariatric surgeons in Houston, TX. Indeed, adjustable gastric band surgery is no longer performed in Houston. Band removal for weight loss failure and intractable GERD is the main band related operation we currently perform at Houston Weight Loss Surgery Center. Most band patients referred to our practice have gastric pouch and esophageal dilation as well as hiatal hernia leading to severe acid reflux disease.

Gastric band was developed based on the assumption that gastric volume reduction by itself results in durable weight loss. This erroneous assumption has been largely debunked by multiple studies showing that obesity is a hormonal disorder. Effective weight loss surgery like sleeve gastrectomy alters some of these hormones leading to durable weight loss. Surprisingly, some bariatric surgeons still advocate the use of gastric banding like Jon Gould, MD who wrote an invited commentary to this study titled “Considering the Role of the Laparoscopic Adjustable Gastric Band: Do Not Throw the Baby Out with the Bathwater”. He argues that gastric band surgery still has a role to play in bariatric surgery. According to Dr. Gould it takes a committed bariatric surgeon and equally committed patient for gastric banding to succeed. They say old habits die hard and despite the overwhelming evidence regarding obesity pathophysiology bariatric surgery mechanism of actions some surgeons still linger in the past. Neither patient will power nor bariatric surgeon commitment can reverse the complex neuro-hormonal disorder that lead to fat accumulation. These false assumptions that are still being used to push for procedures like gastric balloon and endoscopic sleeve gastropalsty no longer have a place in a twenty first century bariatric and metabolic surgery practice. So, let’s throw this baby out for good, with its bathwater, and save our patients unnecessary complications and disappointment. There is no role for gastric banding in any obese patient population. It is time for the FDA to withdraw its approval of such a device.

#### Are You an Early Adopter of Endobariatric Surgery?
Surgery has always been a field in evolution. Surgical procedures and techniques have greatly evolved over the past 100 years. The most dramatic change has been the advent of minimally invasive and endo-luminal surgery. Large incisions and long hospital stays have quickly been replaced with small ones with minimal postoperative pain and very short hospital stays. Just few years ago, as a surgery resident in training, I was performing open gastric bypass procedures. Large deep incisions, wound infections, significant pain, limited mobility, thromboembolic events… crippled weight loss surgery patients and prolonged their hospital stay. The advent of laparoscopy has deeply changed this situation leading to a rapid rise in bariatric surgery popularity.

Currently, the mortality rate of laparoscopic gastric bypass surgery is 0.15% and gastric sleeve mortality is even lower. Laparoscopic gastric sleeve and bypass surgery patients spend on average one night at the hospital prior to discharge. Weight loss surgery patients are able to ambulate and start liquid diet on the same day of surgery. Bariatric surgery became less scary and more appealing to many patients. Yet, only 2% of eligible patients who are morbidly obese opt for surgical treatment each year.

There are many factors contributing to this low percentage. The stigma of undergoing surgery is one of them. Endoscopic bariatric procedures seem like an attractive alternative to laparoscopic surgery. Patients like the concept of “weight loss surgery without the surgery”. Weight loss surgeons are equally eager to jump on the bandwagon. However, adopting new fads without substantial evidence of their effectiveness seems irrational to me. This is especially true when the underlying mechanism of these new endoscopic weight loss techniques contradict everything we have learned so far about metabolic surgery. The best example is gastric balloon placement. A purely restrictive procedure that is doomed to fail simply based on its mechanism of action. The procedure was approved by the FDA but most bariatric surgeons in Houston did not embrace it. Endoscopic bariatric procedures have to mimic the metabolic effects of gastric sleeve surgery to be adopted. A purely restrictive endoscopic sleeve that does not alter blood Ghrelin level or increase gastric emptying and post-prandial GLP-1 levels is unlikely to result in durable and significant weight loss. Should we be early adopters of new bariatric treatments that rely on purely restrictive mechanisms of action? The answer is clearly NO. Instead, we ought to investigate and better understand bariatric surgery mechanism of action and accordingly develop endoscopic procedures. It is no longer accepted to develop a weight loss procedure based on mechanical restriction and expect weight loss surgeons to adopt it.

#### Are you drinking enough water this summer in Houston?
Your body is composed of 60% water. Staying hydrated keep your body functioning properly. Water facilitates the transfer of electrolytes across cell membranes, promotes nutrient and oxygen circulation, and helps your kidney and liver flush out waste and toxins. You are constantly loosing water especially in the hot summer temperature of Houston. When water intake does not match water losses you become dehydrated. Dehydration results in a sluggish metabolism that may put you at risk for weight gain.
Indeed, a study published in 2003, in the journal of clinical endocrinology and metabolism, showed that drinking 2 liters of water per day increased the energy expenditure by approximately 100 calories. That doesn’t sound a lot, but over one month this is equivalent to 3000 calories or almost one pound of fat. So over a year you may lose up to 10 pounds. Not all research studies agree on the ultimate effect of increased water intake on weight loss among dieters. However, many people go throughout their day a little or a lot dehydrated without realizing it. Daily total water intake recommendations depend on your age, gender, size, and physical activity… If you are cycling in Houston these days you probably need more water than a sedentary person living in North Dakota. The best way to know that you are well hydrated is by checking the color of your urine. If it is clear or light yellow then you are doing well. If it is darker in color you need to drink more water.
Many individuals feel hungry when in fact they are thirsty. It is difficult for the body to differentiate between hunger and thirst. Quenching your thirst with water before grabbing a snack may save you a few extra calories you would have consumed when not needed. Have a glass of water 20 minutes before each meal. Several studies have shown that you will end up consuming fewer calories. Drink water instead of soda, sweet tea, juice or coffee. For years, I developed the habit of drinking coffee every time I felt thirsty. Coffee is a diuretic. This means that coffee promotes water loss in urine leading to dehydration. Coffee is obviously not a hydration beverage. Worse is drinking sweetened beverages throughout the day ending up with hundreds of extra calories in the form of simple sugars. The best beverage to drink is simply water. To stay hydrated, I keep a glass of water on my desk at work, and I sip on water throughout the day. When I workout I always carry with me at least 2 large insulated sports bottles of water. Before I go for a workout, I drink a cup of water and when I wake up in the morning a drink a cup of water before breakfast. You can add a fruit like a banana or an apple to replenish your electrolytes during intense workout but remember the best hydrating fluid is water.

#### Bariatric Surgery and Esophageal Adenocarcinoma
Esophageal adenocarcinoma is the fastest rising cancer in the US. Obesity, and GERD are well known risk factors for esophageal adenocarcinoma development. Weight loss surgery like sleeve gastrectomy and Roux-en-Y gastric bypass are effective solutions for both obesity and GERD. Therefore, obese patients undergoing gastric sleeve or gastric bypass surgery are expected to have lower incidence of esophageal adenocarcinoma. A recent population based cohort study published in SOARD (Surgery for Obesity and Related Diseases) shows the opposite. The article is titled “Esophageal adenocarcinoma after obesity surgery in a population-based cohort study”. John Maret-Ouda et al analyzed 34437 patients who underwent weight loss surgery between 1980 and 2012 in Sweden. 8 cases of esophageal adenocarcinoma occurred after weight loss surgery compared to 53 detected esophageal adenocarcinoma cases in 123695 obese individuals who did not undergo any obesity surgery. Using Cox regression, the authors demonstrated no difference in esophageal adenocarcinoma risk between obese patients who had weight loss surgery and those who did not.

The study is quite unique since esophageal adenocarcinoma is not well studied following bariatric surgery. However, this study has two major limitations that undermine its relevance and importance. The first limitation is related to the small number of esophageal adenocarcinoma cases resulting in limited statistical power. The second limitation is related to the fact that most esophageal adenocarcinoma cases occurred in Lap band and vertical banded gastroplasty patients. Both procedures are known to increase the risk of GERD. Nissen fundoplication surgery has been shown to cause Barrett esophagus regression. Both gastric bypass and sleeve gastrectomy are excellent anti-reflux procedures and should theoretically offer the same protective effect against Barrett’s esophagus and esophageal adenocarcinoma. In fact, obese patients with GERD or Barrett’s esophagus are best treated with an effective weight loss procedure like sleeve gastrectomy and Roux-en-Y gastric bypass. Gastric banding in the form of lap band and VBG are no longer offered due to poor weight loss results. Furthermore, lap band surgery alters the esophago-gastric motility in favor of acid reflux development. Therefore, lap band surgery may potentially increase the risk of esophageal adenocarcinoma.

#### Bariatric Surgery Weight Loss Outcome at VA Medical Centers
This month I read a very interesting study on long term weight loss outcome following bariatric surgery performed at Veterans Affairs, VA, medical centers. The first study is published online in JAMA Surgery by first author Matthew Maciejewski from Durham VA medical center. The retrospective study evaluated long-term weight loss in 1787 veterans who underwent gastric bypass surgery in VA facilities between 2000 and 2011. The majority of patients were white males with a mean BMI at 47.7. The control groups consisted of 5305 patients who did not undergo surgery and had a mean BMI of 47.1. The 10 year follow up rate was around 82% for the gastric bypass group and 67.4% for the control group. At 10 years, the majority of gastric bypass patients have lost more than 20% of their pre-operative weight compared to 11% of the control group. Only 3% of the gastric bypass patients have gained their weight back at 10 years.

Gastric bypass surgery remains the gold standard weight loss procedure with an extensive high quality data supporting its efficacy and durability. Gastric bypass surgery has stood the test of time and once again we enjoy reading an excellent evaluation of long term weight loss results following gastric bypass surgery.

Weight loss, however, is not the only benefit reaped from gastric bypass surgery. Resolution of many obesity related co-morbidities like type 2 diabetes and hypertension is equally important. Some of these metabolic benefits of gastric bypass surgery are independent of weight loss. It would be interesting to compare the incidence of type 2 diabetes in both the gastric bypass and control group over a ten year period.

#### Behavior, Biology and Bariatric Surgery Outcomes
I read with great interest the recent article, “Postoperative Behavioral Variables and Weight Change After Bariatric Surgery” by Mitchell et al published in JAMA Surgery.  The article is a longitudinal assessment of bariatric surgery in a multi center observational cohort. 10 hospitals participate in this cohort. A total of 2022 patients were recruited over a 3-year period and followed for at least 3 years after surgery. 1513 patients underwent Roux-en-Y gastric bypass surgery and showed 16% weight loss variability over the 3-year observation period following surgery. According to this study, this variability was explained by 3 behavior related variables including weekly self weighing, stopping to eat when feeling full and not eating continuously throughout the day. The authors found that those patients who started to self weigh after surgery, stopped eating when feeling full, and stopped eating continuously during the day after surgery lost 14% more body weight compared to those who did not.

The authors are to be congratulated on well written article and on their efforts to shed light on a much needed subject in bariatric surgery. What determines weight loss after weight loss surgery? Why do some patients loose more weight than others and how to best maintain weight loss several years after bariatric surgery? Obesity is a complex multifactorial problem. The “obesogenic” environment in which we live coupled with our genetic makeup is a perfect recipe for weight gain. It is quite amazing how bariatric surgery is able to reverse the damaging effects of our lifestyle leading to dramatic weight loss in a relatively short amount of time. By cutting or bypassing the stomach and more specifically the gastric fundus the interaction between ingested food and gastrointestinal tract changes. As a result, the secretion of a number of gastrointestinal hormones is altered in such a way to favor weight loss. Appetite and hunger decrease and the amount of ingested calories go down. The set point is reset and weight stabilizes at a new level. Each patient has a unique set point. Some patients loose 50% of their excess weight and others loose 90% in the first year after surgery. Several studies have attempted to determine weight predictors but failed to find one. Long-term weight loss after gastric bypass and sleeve surgery is however affected by the same factors that have caused obesity in the first place. A sedentary lifestyle and poor diet can reverse all the physiological changes brought by a gastric sleeve or bypass leading to obesity recurrence. The causes that lead to obesity in the first place, i.e. the “obesogenic” environment, are still present. Bariatric patients who succeed in maintaining the weight loss after gastric sleeve or bypass surgery are those who learn how to adopt and maintain a healthy lifestyle.  In other words, they use bariatric surgery as a tool to reset their metabolism but then maintain their weight by avoiding junk food, choosing lean proteins, eating vegetables and fruits, limiting their portions, weighing themselves and watching their weight, avoid skipping meals and grazing on food throughout the day… People tend to forget that metabolic surgery has no effect on our genetic make up or the environment in which we live. We cannot change our genes but we can definitely control our habits and lifestyles. Weight loss surgery is a bridge to a healthier you but maintaining this new state is up to you and only you. There is no doubt that bariatric surgery is not an easy way out for many of us. In today’s modern environment, we are all vulnerable to weight gain and regain after weight loss surgery. Mitchell and colleagues conclude in their study that structured behavioral programs must be created to help support bariatric patients after weight loss surgery. Even though patients have decided to become healthier by undergoing bariatric surgery, sustained change of behavior remains difficult.

#### Best Diet for 2018
It is the beginning of a new year, and for most Houstonians, weight loss is a priority. The new year resolution for a healthier lifestyle is synonymous with a good diet and the question of what plan to follow for year 2018 assails most of us. Indeed, deciding what to eat on a daily basis has become a dilemma for most of us. Should we adopt a high protein or vegan diet? Should we buy organic or conventional apples? Should we eat butter and cheese or avoid dairy products altogether? Is sugar bad for me even in moderation? And how about soy products, food additives, frozen meals…

The omnivore dilemma, as Michael Pollan describes our eating situation, is a daunting reality in Houston. Almost every patient I treat at Houston Weight Loss Surgery Center, requests the “diet plan” to follow. The reality is that there is no one diet plan that fits all. There are basic principles, however, that the nutrition experts at Houston Weight Loss Surgery Center recommend.

First, the best diet to adopt is a diet you can maintain for the long term. The longevity of your diet is determined by many factors including your eating habits, your access to certain food items, your grocery shopping, your family and friends… For instance, if you don’t have time in the morning to prepare breakfast, then sooner or later you will go back to grabbing an egg McMuffin on your way to work. If you don’t have time to shop for fresh produce, you will eventually stop cooking at home and go back to eating out. Any diet plan you adopt must fit your lifestyle to be able to maintain it. Adopting a plan for the first 3 weeks of January only, is not going to help you for the long run.

Second, contrary to what most commercial diet plans advocate, a successful plan requires you to cook at home. Home cooking is the most important thing you can do for yourself and your health for 2018. Only you can control the ingredients in your food. Restaurants and food companies will not do it for you. You will never add any artificial ingredients or excessive amounts of fat, sugar and salt to home prepared meals. Once you start relying on yourself and you are able to prepare a meal at home, from scratch, you are on your way to success.

Third, eat local and in season. Limiting your food options to your local environment not only is good for the environment but also for your health. Local produce is fresh, taste better and contains more nutrients than packaged food that is at least 2 weeks old. Locally grown food has limited variety. Limited food variety forces you in a routine. You tend to consume similar items on a regular basis. Boring food is good for weight loss. Exotic food items are more likely to be consumed for pleasure or out of curiosity rather than due to hunger.

Fourth, eat mostly plants. Fiber is an essential element in our diet for colonic health. Numerous studies have shown that gut bacteria affect our physical and mental health at different levels. Fiber is what these bacteria feed on. Fiber is calorie free and it fills you up allowing to control your hunger and limit your calorie intake per meal. I am not a huge fan of the high protein and high fat diets like Atkins and south beach. Meat, especially non-grass-fed meat with high fat content ought to be consumed in moderation. Studies have clearly shown a strong association between meat consumption and a number of diseases like cancer and hypertension.

Fifth, STOP sugar, and other forms of processed carbohydrates with a high glycemic index. The average American consumes 100 pounds of sugar per year. This is too much for the body to process especially in the setting of sedentary lifestyle. High glycemic index food items, in the presence of insulin resistance, are transformed into fat. Excessive fat is deposited in liver and skeletal muscle causing further increase in insulin resistance and more weight gain.

Last but not least, a perfect diet in the absence of daily physical activity is bound to fail. An exercise routine in conjunction with a balanced and reasonable diet that fits your lifestyle can help you improve your health in 2018. Remember that Rome was not built in one day. Start changing your habits slowly and gradually to achieve durable success. Develop a healthy food culture in your house that can last for years to come. You don’t need Weight Watchers or Nutrisystem to succeed. You just need to be get in the right mind set.

#### Best Sleeve Surgery in Houston
Not all gastric sleeves are created equal. Therefore, not all gastric sleeves will result in the same amount of optimal weight loss. Gastric sleeve surgery technique is crucial to achieve the best possible weight loss while at the same time avoiding complications like staple line leak and acid reflux development.
Understanding stomach anatomy and physiology as well as acid reflux pathophysiology and most importantly, gastric sleeve surgery mechanism of action is crucial to offering the best sleeve surgery in Houston.
A twisted or narrowed staple line increases the risk of complications and development of acid reflux disease. Most importantly, it hampers accelerated emptying of gastric content, a key factor in weight loss. Similarly, incomplete gastric fundus resection and proper contouring of sleeve gastrectomy results in poor weight loss and acid reflux.
Lastly, neglecting to repair a concomitant hiatal hernia during gastric sleeve surgery results in severe acid and bile reflux symptoms. GERD following sleeve gastrectomy is hard to control with medications. GERD symptoms worsen with time, even after losing your excess weight, due to gastric sleeve migration into the chest. Proper hiatal hernia reliably stops acid reflux and is an important aspect of quality gastric sleeve surgery in Houston.

#### Best Treatment for Gastroparesis: Gastric Bypass or Gastric Sleeve?
Gastroparesis or delayed gastric emptying occurs when the stomach is paralyzed and gastric emptying is impaired. As a result, patients report bloating, nausea, vomiting, and pain. The underlying pathophysiology of gastroparesis is poorly understood. The cause of gastroparesis is also unknown. When patients with diabetes develop gastroparesis, the condition is called diabetic gastroparesis. It appears that in diabetic patients enteric nerve damage results in gastric dysmotility. However, the relationship between diabetes and gastroparesis is far more complex than a simple neuropathy. Normally, rising blood sugar levels halt gastric emptying as a protective measure against further nutrient passage into the intestines and sugar absorption. In type 2 diabetic patients abnormal gastric emptying may be the cause of diabetes rather than the result. In fact, type 2 Diabetes may be looked at as a gastro-intestinal motility disorder resulting in insulin resistance. Dr. Mason, the father of bariatric surgery, is an avid proponent of this theory. The early resolution of type 2 Diabetes immediately following gastric bypass and sleeve surgery is partly secondary to faster delivery of food to the distal small bowel. Gastric sleeve increases gastric emptying allowing food particles to reach the distal bowel to stimulate more L cells leading to increased GLP-1 secretion. L cells are specialized cells that react to glucose in ingested food and secrete several hormones like GLP-1 that affect glucose metabolism. GLP-1 stimulates insulin secretion and blocks glucagon secretion hence improving post-prandial blood sugar levels.
Several studies have shown that gastric sleeve surgery increases gastric emptying. Few years ago, I used this concept to treat a severe case of diabetic gastroparesis in a 45-year-old male. I performed a longitudinal gastrectomy to mimic the effects of gastric sleeve and improve gastric emptying. I also added a duodeno-jejunostomy to promote duodenal emptying. The patient immediately improved and was tolerating regular diet few days after surgery. Interestingly, his diabetes resolved immediately after surgery. This observation shows again that type 2 Diabetes is primarily a gastro-intestinal motility disorder. I did not consider a gastric bypass in this particular patient because the stomach was massively dilated. Gastric remnant secretion would accumulate in the stomach causing symptoms. A recent study from the Cleveland Clinic showed that gastric bypass surgery is effective in morbidly obese gastroparesis patients and safer than subtotal gastrectomy. The series was small (7 patients) and the follow up was short. Two patients were converted to subtotal gastrectomy for persistent gastroparesis related symptoms following gastric bypass surgery. In my opinion, gastroparesis is a generalized motility disorder that affects the duodenum and sometimes the entire small bowel. Simply bypassing the stomach and proximal bowel may not resolve the symptoms especially in severe cases. A modified gastric sleeve or longitudinal gastrectomy is a more effective option that addresses the underlying problem. By resecting the gastric fundus and most of the greater curvature, stomach compliance decreases leading to improved gastric emptying. Furthermore, the malfunctioning gastric pacemaker that is located along the greater curvature is eliminated and potentially leading to increased motility. I recommend leaving the antrum intact as it represents the gastric pump and may help promote gastric emptying.
In summary, gastrointestinal motility affects many functions in the body and contributes to many diseases like acid reflux, diabetes and obesity. Gastric motility patterns are highly coordinated and still poorly understood. Lessons learned in gastric sleeve surgery may be applied to severe refractory gastroparesis cases. Future studies are needed to establish longitudinal gastrectomy as an effective treatment modality for gastroparesis.

#### Bile gastritis after Sleeve Gastrectomy
Jenny from Humble sent us this question: “Had sleeve done in 2014. After EGD done 1/2020 it showed I had lots of bile in my stomach. Have bile reflux, take 40mg Omeprazole DR twice a day. Still have burning in throat, chest, esophagus. Also having hiccups and belching after eating. Cut out all caffeine, sodas, acidic fruits, and tomatoes. Still no difference. Also fried foods. Just hurting when I eat anything. EGD also showed esophagitis. 65 and getting tired of all of this daily. Will go to Dr. 5/21. Just asking for more advice or what I can do. Thanks JD”.

Dear Jenny,

Bile gastritis and bile reflux after sleeve gastrectomy is indicative of hiatal hernia. Hiatal hernia is a defect in the diaphragm hiatus. The diaphragm or breathing muscle has an opening in its center. The esophagus or food pipe goes through this opening to join the stomach in the abdominal cavity. The opening is wide enough to allow for the esophagus to go through. If the opening is large a hiatal hernia forms and the stomach herniates through the hiatal hernia into the chest.

Obesity is a major risk factor for hiatal hernia formation. Most overweight individuals have a hiatal hernia. Therefore, most obese patients undergoing sleeve gastrectomy must have a concomitant hiatal hernia repair. If hiatal hernia is not repaired, gastric sleeve herniates into the negative pressure area of the chest. This results in bile reflux from the duodenum into the stomach lumen and eventually ending in the esophagus.

Bile reflux may be worse than acid reflux in terms of damage to esophagus lining, severe burning symptoms and esophageal cancer development. Most importantly, bile reflux does not respond to proton pump inhibitors like Omeprazole and Nexium. I strongly recommend you consult with the best acid reflux and weight loss surgery specialist in your area to get evaluated and treated. Hiatal hernia repair is quite effective at stop bile reflux especially if gastric sleeve lumen is not narrowed or twisted.

#### Bile Gastritis Following Gastric Sleeve Surgery
A gastric sleeve patient was referred to our weight loss surgery clinic for severe acid reflux, epigastric pain and food regurgitation. Her symptoms are worse at night: she wakes up from sleep choking and gasping for air several times a week. The patient has already been started on high dose proton pump inhibitors for several weeks prior to presentation to our office with minimal improvement. She has lost most of her excess weight over the past one year after her gastric sleeve surgery. Her GERD related symptoms, however, have gotten worse. Interestingly, the patient suffered no reflux related symptoms prior to her surgery.

An upper endoscopy was performed to evaluate her problem. It revealed a large hiatal hernia with around one third of the gastric sleeve herniated into the chest. Diffuse gastritis and a bile filled gastric sleeve lumen were noted. The incisura angularis was widely open with apparent twisting and there was no evidence of a retained gastric fundus. Multiple biopsies from the gastric mucosa were taken and showed moderate to severe inflammation with no evidence of h pylori infection. Given the amount of bile present, distal partial small bowel obstruction was suspected. Gastroparesis was also considered as a potential cause for bile stasis in the gastric lumen. Accordingly, a gastric emptying study and a CT scan of abdomen and pelvis were ordered and were both normal.

As a result, we offered the patient a hiatal hernia repair with possible conversion of gastric sleeve to Roux-en-Y gastric bypass as the most reliable solution for her problem. Her medical insurance, however, did not approve the gastric bypass and we limited our intervention to hiatal hernia repair only. Intraoperatively, the gastric sleeve was completely reduced from the chest. The hernia sac was dissected and the hiatal defect repaired with no tension. The abdomen was carefully explored and no further abnormalities were noted. The patient did very well and all her GERD related symptoms including food regurgitation and epigastric pain resolved.

Six months after surgery, our patient continued to be symptom free and decision was made to repeat the upper endoscopy to re-evaluate the gastric mucosa. There was no evidence of hiatal hernia or esophagitis. The gastric mucosa has completely healed with no residual inflammation or bile stasis.

So what was causing bile reflux into the gastric lumen? Gastric sleeve surgery improves gastro-intestinal motility. As a result, bile is less likely to reflux into the stomach even in the presence of a pyloromyotomy or pyloroplasty. The most likely explanation, in my opinion, is that the herniated gastric sleeve was acting like a suction pump drawing bile from the duodenum into the stomach. Indeed, the negative pressure in the chest was being effectively transmitted into the gastric sleeve lumen. Negative pressure within the gastric sleeve promoted bile reflux from the duodenum across the pylorus leading to bile induced gastritis. By repairing the hiatal hernia, re-establishing the intra-abdominal esophagus, the negative inspiratory pressure was no longer transmitted to the sleeve lumen hence preventing the suction effect. Interestingly, sleep apnea can cause or exacerbate acid reflux by a similar mechanism. Greater respiratory effort increases the pressure gradient across the lower esophageal sphincter and the diaphragm leading to retrograde flow of gastric content into the esophagus especially in the presence of a hiatal hernia.

Prior to gastric sleeve procedure, our patient antacid barrier has most likely reformed within the hernia sac hence preventing reflux. At Houston Heartburn and Reflux Center, we encounter many patients with asymptomatic large hiatal hernia. By performing a gastric sleeve, however, without addressing a concomitant large hiatal hernia, GERD will most likely develop. At Houston Weight Loss Surgery Center, we advocate proper hiatal hernia repair during gastric sleeve surgery. Obese patients with large hiatal hernias and a BMI more than 50 presenting for gastric sleeve surgery are either staged or placed on high protein low calorie liquid diet to reduce their liver size and weight allowing for a safer approach.

#### Can Gastric Bypass Surgery Survive the Assault of Cheese Crackers?
Recently I have seen a good number of patients who had successful gastric bypass surgery several years ago and now are gaining weight back. Erin, for example, has lost 90 pounds after her bypass surgery and has managed to maintain the weight loss. For nine years, Erin has enjoyed her new life; free of medications for hypertension and diabetes, she traveled all over the world, hiked the Appalachian trail, enjoy her daily swimming and many other activities she was not able to do before her weight loss surgery.
Suddenly, Erin started gaining weight (20 pounds over the past 8 months). She still has excellent restriction and appetite control. Erin, however, admits to “munching on peanut butter and cheese crackers throughout the day”. She reports that she has recently developed this new habit and started buying boxes of cheese crackers to stock her pantry!
I have always been intrigued by this behavior. Why do bariatric patients revert to old habits? Habits they have overcome longtime ago and as a result they have enjoyed years of healthy happy living.
The answer is STRESS. The majority of patients that I have encountered in my practice, who regain weight many years after gastric bypass surgery report new onset anxiety and stress.
Chronic stress is one of the main reasons for weight gain in the 21st century. Whether you had bariatric surgery or not, chronic stress increases body cortisol level, which in turn leads to increased insulin resistance. High insulin resistance prevents the movement of sugar from the blood stream into muscles to be metabolized. Instead, excess sugar moves into fat stores favoring weight gain.
Furthermore, in addition to disrupting the metabolic machinery that burns excess calories and fat, chronic stress prevents an individual from exercising. Most people these days respond to stress by stewing in frustration and anger. Instead of moving, eating becomes the activity of choice to relieve stress. They stock their homes with an endless array of junk food items (crackers, pretzels, chips, ice cream, candy bars…) for munching on day and night. Grazing on junk food is the worst thing you can do to your gastric bypass. In addition to the hundreds of calories added per day, the efficacy of gastric bypass in dealing with processed food is very limited. Our intestines are not made to handle junk food. The end result of junk food consumption is invariably weight gain, diabetes, depression, hypertension, and sleep apnea…
In my next blog, I will go over techniques and solutions for coping with stress. Until then, try to relax, exercise and eat healthy.

#### Can I lose Too Much Weight After Gastric Sleeve Surgery?
Grace from Katy, Texas sent us this question: “How much weight do I lose after sleeve gastrectomy? I am concerned of losing too much. Can you not take too much of the stomach out? Thank you.”

Dear Grace,

Gastric sleeve surgery or sleeve gastrectomy is currently the most commonly performed weight loss surgery in Houston. Sleeve gastrectomy is both safe and effective. Properly performed sleeve gastrectomy results in a well contoured, “banana” shaped, stomach with no narrowing or twisting of gastric sleeve lumen. The art of gastric sleeve surgery is to resect just enough to achieve the best metabolic response leading to the most optimal weight loss outcome. If too much of the stomach is taken out, functional narrowing or stricture formation develop. In this case, patients develop acid reflux, nausea, vomiting, and may experience excessive weight loss. On the other hand, if too little of the stomach is resected patients will achieve suboptimal weight loss.

Weight loss stabilizes around one year after sleeve gastrectomy. Bariatric patients do not lose weight indefinitely because they reach an equilibrium point between energy consumption and energy expenditure. This equilibrium point depends on many factors that are not fully understood. Consequently, we cannot predict how much weight does a patient exactly lose after sleeve gastrectomy. Studies show that on average sleeve gastrectomy patients lose 70% of their excess weight. Some lose more and some lose less. No one, however, loses too much weight to the point of becoming malnourished.

#### Case of the week: Gastric Sleeve Surgery Following Nissen Fundoplication
The patient is a 54-year-old female with morbid obesity presenting for weight loss surgery evaluation. She is particularly interested in gastric sleeve surgery. The patient underwent hiatal hernia repair and Nissen fundoplication 14 years ago for severe GERD. She reports excellent acid reflux symptom control but recently she has been experiencing heartburn, bloating, excessive belching. An upper endoscopy showed a Hill grade 3 hiatal hernia with 5 to 6 cm diaphragmatic opening and 8 cm axial displacement. The Nissen fundoplication appeared intact and has herniated along the rest of the upper stomach into the chest.

The traditional approach to such a case is hiatal hernia repair and Nissen fundoplication conversion to gastric bypass. Ideally, the fundoplication is taken down prior to gastric pouch creation. Occasionally, the fundoplication is adherent to the esophagus and the pouch can be constructed below the fundoplication thus avoiding esophageal injuries and minimizing complications.

A newer approach entails conversion of Nissen fundoplication to Gastric sleeve surgery with hiatal hernia repair. Gastric sleeve surgery, when properly performed, is as effective as gastric bypass in terms of acid reflux control. The fundoplication is typically taken down prior to gastric sleeve resection. New reports have recently emerged about the Nissen-sleeve and Rosetti-sleeve surgeries whereby part of the gastric fundus is preserved following gastric sleeve surgery to perform a fundoplication. Weight loss results at one year were comparable to a traditional gastric sleeve procedure.

Accordingly, I started offering obese patients with previous Nissen fundoplication, a fundoplication preserving sleeve gastrectomy. The greater curvature is mobilized and gastric sleeve resection is performed up to the fundoplication level. Care is taken to resect the redundant posterior fundus to avoid a large pouch in that area. A concomitant recurrent hiatal hernia is repaired. My short-term weight loss results in a limited series of patients are similar to regular gastric sleeve weight loss outcomes. Patients report excellent appetite and portion control and no GERD symptoms.

Fundoplication preserving gastric sleeve surgery is the least invasive surgical weight loss option for obese patients with history of anti-reflux surgery. This approach is particularly suitable for patients with significant adhesions around the gastro-esophageal junction. I predict that long-term results of fundoplication preserving gastric sleeve surgery are similar to a traditional sleeve gastrectomy and this approach is likely to become the preferred revision procedure for this particular group of patients.

#### Case of The Week: Lap Band and Pseudo-achalasia
Adjustable gastric banding results in the formation of a thick fibrous capsule around the distal esophagus. In most cases the capsule is around 3 to 4 mm in thickness and spontaneously resolves after band removal. The patient I am presenting in this blog developed a thick fibrous capsule following lap Band placement measuring more than one cm in thickness. She is 30-year-old female with BMI=55 who presented to my office for evaluation of failure to lose weight 3 months after lap band placement at an outside institution. Her initial bariatric surgeon has attempted several times to adjust her band. Each adjustment had resulted in obstructive symptoms including nocturnal cough, food regurgitation, vomiting and inability to tolerate regular diet. The band was completely emptied and the patient was recommended lap band removal.

Prior to band removal, an esophagogram showed a dilated and tortuous esophagus with distal tertiary esophageal contractions. Contrast emptying from the esophagus into the stomach was delayed and incomplete. The lap band was in good position. There was evidence of narrowing of the distal esophagus at the level of the band. Esophageal manometry showed 90% failed contractions, weak contractile wave amplitude and decreased distal contractile integral. Residual lower esophageal sphincter pressure was slightly elevated at 17 mmHg while basal lower esophageal sphincter pressure was within normal. These findings are consistent with esophageal outflow obstruction. Weak contractions are either the result of prolonged esophageal outflow obstruction or intrinsic esophageal motility disorder. The patient may also evolve into achalasia with absent peristalsis and failure of the lower esophageal sphincter to relax. Currently, however, she does not meet the diagnostic criteria for achalasia.

The decision was made to remove the lap band and associated fibrous capsule as a possible cause of lower esophageal partial obstruction. Intraoperatively, a thick fibrous capsule, measuring more than one cm in thickness, was noted around the distal esophagus. The capsule was easily dissected off the esophageal wall and most of the anterior capsule was resected. Intraoperative endoscopy revealed a patent GEJ.

6 months after band removal, repeat esophagogram and manometry showed resolution of distal esophageal tertiary contractions, improvement in esophageal dilation, mild distal esophageal narrowing, and increased contractile wave amplitude and normal residual lower esophageal pressure. Patient subsequently underwent sleeve gastrectomy. Inspection of the GEJ revealed no residual fibrosis that might have prevented proper tissue stapling.

This case represents an unusual fibrotic reaction to Lap Band placement. The fibrous capsule that developed over a short period of time, has resulted in a pseudo-achalasia. Esophageal outflow obstruction led to nocturnal cough and food regurgitation that prevented band adjustment and possible weight loss. Performing a concomitant sleeve gastrectomy at the time of band removal might have been possible after capsulotomy. However, waiting 6 months and allowing the tissue to heal and recover prior to stapling is associated with a lower leak rate and better outcome.

#### Case of the Week: Sleeve in the Setting of a Large Hiatal Hernia
The patient is a 50 year-old female who underwent gastric sleeve surgery in Mexico approximately a year ago. Her comorbidities prior to surgery included hypertension and sleep apnea. She did not experience heartburn or food regurgitation prior to surgery. She underwent the procedure with no complications. Her operative report describes an uneventful gastric sleeve resection and anterior hiatal hernia repair consisting of anterior crural approximation with suture fixation of the gastric sleeve to the left crus. 12 days after surgery she started experiencing severe daily heartburn and food regurgitation. She was placed on proton pump inhibiters, Carafate and Zantac with very little symptom improvement. She underwent an upper endoscopy that showed a Hill grade 4 hiatal hernia with around 6 cm axial displacement and 4 to 5 cm diaphragmatic opening. The incisura angularis was widely open with no apparent narrowing.

Decision was made to explore the patient and repair the hiatal hernia and possibly convert the gastric sleeve to Roux en Y gastric bypass. Laparoscopic abdominal exploration revealed a large hiatal defect with gastric sleeve herniation into the mediastinum. There were anterior adhesions suggestive of previous anterior crural repair and lateral stitches between the gastric sleeve and left crus suggestive of an attempt at fixating the sleeve below the diaphragm. The gastric sleeve showed no evidence of twisting or narrowing. The gastric fundus was completely resected.

Given the fact that the patient had such a large hiatal defect and no gastric sleeve luminal narrowing, decision was made to preserve the sleeve and repair the hiatal hernia. The hiatus was opened. The gastric sleeve was reduced into the abdomen and the esophagus circumferentially dissected up until 3 to 4 cm of intra-abdominal esophagus was obtained. At this point, the right and left crus were approximated with pledgeted sutures and covered with mesh to reinforce the repair.

Postoperatively the patient did very well. Her heartburn and food regurgitation have completely resolved. She was free of proton pump inhibitors. Her sleep quality greatly improved and she resumed her normal activity within a week after surgery.

Hiatal hernia repair is not about crural approximation. The key to hiatal hernia repair is esophageal dissection and mobilization to restore the intra-abdominal esophagus. The GEJ is a complex anatomic structure that is closely linked to proper functioning of the antacid barrier. Effacement of the angle of Hiss, loss of the diaphragmatic support, and migration of the intra-abdominal esophagus into the negative pressure chest area are some of the factors that contribute to disruption of the GEJ anatomy and function as antacid barrier. Reducing the stomach into the abdominal cavity without dissecting the hernia sac and mobilizing the esophagus is a useless move. Attempting to fixate the stomach to the crura is equally futile. Esophagus, GEJ and stomach must be completely freed from the chest into the abdomen with no tension to ensure success and durability of the repair. Our patient had no GERD related symptoms prior to her sleeve surgery. The angle of Hiss and GEJ anatomy needed to insure proper functioning of the antacid barrier was most likely preserved within the hernia sac in the chest. I have noticed this finding in several patients with fairly large hiatal hernias but they have no reflux. Following gastric sleeve resection and anterior crural repair in Mexico, the patient started developing symptoms. The antacid barrier that has reformed in the chest, within the hernia sac, was disrupted. By properly repairing the hiatal hernia and reducing the sleeve into the abdominal cavity and restoring the abdominal portion of the esophagus, GERD has resolved. This raises an important question that has not been answered yet in the literature. Is hiatal hernia repair with gastric sleeve surgery equivalent to hiatal hernia repair with Nissen fundoplication? In other words, is a properly performed gastric sleeve surgery equivalent to a Nissen procedure in the setting of hiatal hernia and GERD? More studies are needed in the future to answer this common problem affecting obese and overweight patients in the H city.

#### Causes of Obesity
Obesity is neither a cosmetic issue nor a psychological problem. It is very important for our patients to understand that obesity is a CHRONIC PROGRESSIVE MEDICAL DISEASE. Our understanding of obesity, energy metabolism and weight control has greatly evolved over the past few years. We now understand that many hormones control body weight and obesity is the result of an imbalance in these complex hormonal systems.
Therefore, obesity is no longer viewed as a consequence of over-eating, self-indulgence or lack of self-control. Rather, obesity is the result of multiple environmental and genetic factors that disrupt a variety of hormonal systems that control body weight and energy metabolism. The disruption of these hormones results in the progressive body fat accumulation.
In the United States, 68% of all adults are overweight. The environment in which we live (Sedentary and stressful lifestyle in addition to a highly processed diet low in fruits, vegetables, legumes, seeds, nuts, and quality proteins) puts us at risk for excessive fat accumulation. Accordingly, overweight individuals are victims of an “obesogenic” environment. Overweight patients are not culprits and should not feel guilty about their weight problem. 
To summarize, obesity does not simply occur because you eat more food. Therefore, the solution to obesity is not as simple as lowering your food intake. Any long-term and effective solution for obesity has to address the underlying cause: Disrupted Hormones. If you are concerned with your weight, please contact us so we can determine the best weight loss solution for you.

#### Continuous belching following gastric sleeve surgery
This case was posted on the American College of Surgeons, bariatric portal, for discussion.

“A 60-year-old patient had a sleeve gastrectomy 4 months ago for morbid obesity. Patient had been doing well until 3 weeks ago when she began to have continuous belching. She noticeably gulps air and then immediately belches. This is almost every minute but is NOT present when asleep and nurses notice sometimes ceases when distracted.

CT scan and UGI contrast study were essentially normal. Air accumulation was noted in proximal sleeve. No gastric lumen stenosis noted. Contrast emptying from the stomach into the duodenum was within normal. Upper endoscopy was unremarkable and no hiatal hernia was noted.

Are these symptoms related to gastric sleeve surgery?
 Is this a variety of frothing?
 Is conversion to RNY indicated?”

Excessive belching and burping or eructation are common GERD symptoms. Patients who suffer from acid reflux disease tend to swallow air and saliva to neutralize acid reflux more than average. Swallowed air accumulates in the gastric fundus. Increased transient lower esophageal sphincter muscle relaxation because of esophago-gastric dysmotility results in air reflux.

Air reflux is diagnosed using pH impedance. pH impedance probe is positioned in the esophagus using esophageal manometry. It is the preferred diagnostic tool for GERD diagnosis following gastric sleeve surgery. Acid reflux may occur following sleeve gastrectomy if the gastric sleeve is poorly performed and/or a concomitant hiatal hernia is not repaired or inadequately repaired.

At Houston Weight Loss Surgery Center, we have had great success resolving GERD following sleeve gastrectomy. In 80% of the cases, we could salvage the sleeve and promote weight loss. In the remaining cases, gastric sleeve conversion to gastric bypass was needed due to significant gastric sleeve lumen narrowing.

The case presented above warrants full GERD workup including esophageal manometry and pH impedance. The gastro-esophageal junction must be carefully and closely examined for a hiatal hernia. Bile gastritis is commonly encountered in the case of a hiatal hernia and sleeve gastrectomy. the patient is considered behavioral only when the complete GERD work up is negative.

#### Control your portion size and stop weight gain
“Don’t Super Size Me”… Control your portion size and stop weight gain
Restaurants in Houston have super-sized everything, from drinks to meals. We have developed overeating habits inside and outside our homes. Large meals over-stretch the stomach. Over time, repetitive overeating results in irreversible progressive enlargement of the upper part of the stomach. When this happens you need to eat larger meals to fill your stomach and control your hunger. Larger meals translate into more calories and more weight gain.
How to avoid overeating?

Do not skip breakfast. Breakfast is the most important meal of the day. Eating a healthy and balanced breakfast controls your hunger throughout the day, especially in the evening. Most individuals who skip breakfast in the morning tend to overeat at dinnertime. A heavy meal at dinnertime
Eat slowly. Do not eat while driving or watching TV. Develop the habit of what we call mindful eating. Listen to your body cues for hunger and satiety. Put down your fork between each bite and chew your food very well.
Eat small meals. Do not “super-size” your meals. Try using a smaller plate at home. One serving of cooked meat is the size of your palm. Fill half your plate with non-starchy vegetables like spinach and green beans. Add 2/3 cup of whole grains like brown rice and avoid saturated fat in heavy dressings and sauces.

If these tips are not helping you loose weight, contact Houston Weight Loss Surgery Center. Dr. Darido offers comprehensive evaluations and effective weight loss treatment solutions in the greater Houston area.

#### Coping with Stress
“God grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference.”
Chronic stress is synonymous with 21st century living and Houston ranks among America’s most stressful cities. According to Forbes magazine, Las Vegas is the most stressful city in the country, followed by Los Angeles, California, and Houston, Texas. Stressful Houstonians are paying a huge price with their health. Chronic stress is associated with many health issues namely obesity, diabetes, hypertension and heart disease. While stress is unavoidable in our life, coping with stress is a must know skill to survive and thrive in our modern society. Many people resort to unhealthy habits like smoking, drinking, and overeating that have deleterious effects on the long run. At Houston Weight Loss Surgery Center, stress management is an INTEGRAL PART of the weight loss treatment plan that we offer to our Houstonian patients.
In 1943, at the peak of WWII, Reinhold Niebuhr, a pastor, theologian and philosopher from New England wrote this prayer: “God grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference.” In one sentence, Reinhold Niebuhr summarized the 4 pillars for coping with stress:

Avoid the stressor
Alter the stressor
Adapt to the stressor
Accept the stressor

It is easier said than done. However, understanding and facing stress rather than stewing in anger and frustration is your only way out. For overeating for hours in front of a TV will only damage your health. Overeating to comfort yourself is the worst coping strategy you adopt for dealing with stress. Soothing your pain with junk food, high sugar, and high fat comfort food will invariably develop into an addiction. An addiction that has fueled the rise of obesity to an epidemic level. You can take action today. Cope with stress and don’t let it control your life.
Here are five effective tips:

Take care of your body and your body will take care of you.
Exercise: Best antidote for stress. Pick an activity you like, hook up with an exercise buddy to motivate you, and make exercise part of your daily routine.
Spend some time in nature: get some fresh air and some sun.
Meditate: Visualize calm. Transport yourself to a happy place 5 minutes everyday. Boost your spiritual side; Get in touch with your inner self. Religious people are happier than atheists in stressful environments. We need religion more than ever these days.
Develop a hobby: Take your mind of negative thoughts and engage in a creative or competitive activity.

#### Cough after Gastric Sleeve Surgery
Tracey from Houston sent us this question: “I am 2 1/2 years post op gastric sleeve surgery and have a terrible chronic cough that no one can seem to get to the bottom of, lungs are clear but constant nasal drainage, coughing and at time throwing up but nothing comes up it’s bizarre.”
Dear Tracey,
Cough is a common acid reflux symptom following sleeve gastrectomy. Acid and bile escape the gastric sleeve up into the esophagus and can reach the throat. Throat irritation by acid and bile leads to cough, hoarseness, sore throat and globus. Globus is the sensation of something stuck in the throat that you need to clear all the time. In certain cases, acid and bile get into the lungs and patients develop asthma.
I recommend consultation with a Houston acid reflux specialist at Houston Heartburn and Reflux Center to rule out acid reflux in the setting of sleeve gastrectomy leading to cough. Workup includes upper endoscopy to check for hiatal hernia, esophagitis, bile gastritis and to evaluate gastric sleeve lumen. A narrowed or twisted gastric sleeve lumen favors acid reflux.
In most cases, hiatal hernia repair is the only treatment you need. Hiatal hernias are very common in patients undergoing sleeve gastrectomy. If a hiatal hernia is not repaired at the same time of gastric sleeve surgery acid reflux occurs.

#### Demystifying the Role of Weight Loss Surgery
There is widespread belief that weight loss surgery is a last resort treatment for patients who are struggling to lose weight. Indeed, most primary care physicians, endocrinologists and cardiologists do not refer an obese patient for gastric sleeve or Roux-en-Y gastric bypass surgery until it is too late. Endocrinologists resort to escalating doses of long acting insulin in hopeless attempts to control blood sugar. Cardiologists spend countless hours chasing high cholesterol and blood pressure. Pulmonologists work tirelessly adjusting CPAP machines to improve breathing and control sleep apnea… The result is disease progression with more weight gain, shortened survival, and poor quality of life.

Weight loss surgery is currently the only effective, reliable and durable treatment for obesity and associated diseases like type 2 diabetes. Furthermore, weight loss surgery is safe with less than 1% mortality and morbidity rates. Accordingly, gastric sleeve and gastric bypass procedures must be considered early in the disease process. Young patients have many productive years ahead of them. The earlier we intervene in a chronic disease, the more effective the treatment can be and the longer it can last. Studies have clearly shown that the longer the duration of type 2 diabetes, the less likely is the resolution rate following laparoscopic sleeve gastrectomy. So why wait? Intervene now to relieve your body from the toll of obesity. Stop the Yo-Yo dieting for good and throw away all the supplements you are taking to lose weight. Reverse the damage obesity has incurred on your health and gain back your life.

If you suffer from excess weight and other obesity related diseases call the experts at Houston Weight Loss Surgery Center for a complimentary consultation.

Reference:

Surg Obes Relat Dis. 2011 Nov-Dec;7(6):697-702.
Ten-year duration of type 2 diabetes as prognostic factor for remission after sleeve gastrectomy.
Casella G1, Abbatini F, Calì B, Capoccia D, Leonetti F, Basso N.

#### Diets and lifestyle changes that speed up your metabolism
Your metabolic rate is how fast you burn energy. It is the corner stone for any successful weight loss solution. Men burn more calories than women. Younger individuals have higher metabolic rates than older ones. This is why we tend to gain weight as we age. The higher the metabolic rate the more likely you can stay lean. While you cannot control your age, gender or genetic background, here are some suggestions that may help you improve your metabolism.
1. Build and maintain your muscle mass
Strength training activates your muscles and boosts your metabolism. Muscle burns more calories than fat tissue. Muscles that are not used tend to be replaced by fat leading to a lower metabolic rate and weight gain.
2. Adopt a daily aerobic exercise routine
Aerobic exercise especially high-intensity workouts raise your metabolic rate. Try short bursts of jogging while walking. Join a cycling class at the gym. I personally had great success with racquetball.
3. Stay hydrated
Houston is very hot in the summer months. If you are mildly dehydrated your metabolism goes down. All energy burning processes in the human body require water. Drink a glass of water before every meal or snack. Keep a bottle of water with you at all times especially when working outside.
4. Choose good sources of protein
Lean protein like turkey, fish, egg white, beans and low-fat dairy products can rev up your metabolism. Adopt a balanced healthy light and fresh diet free of processed food items, sugar and saturated fat.
5. Have 3 meals a day and snack smartly
Do not skip meals especially breakfast. A good breakfast in the morning gives the needed energy to start your day. Skipping breakfast lowers your metabolic rate throughout the day. Choose healthy snacks to maintain your energy. Avoid sweets and white flour. Use fresh fruits and vegetables instead.
6. Do not starve yourself
Avoid starving yourself in the hope of loosing few pounds. Many Houstonians attempt to loose weight by consuming less than 1300 calories a day. This is a recipe for failure. Your metabolic rate goes down with starvation. You end up burning fewer calories than before the diet. In addition, your hunger increases and you end up eating more than you used to eat before.
7. Consider bariatric and metabolic surgery
Last but not least, if you are more than 75 pounds overweight and interested in weight loss, metabolic surgery is currently the most effective approach to increase your metabolism. Gastric bypass and sleeve gastrectomy are currently the most reliable and effective techniques to boost your metabolic rate, curb your appetite, and loose weight.
For more details on effective weight loss solutions please contact our office at 281.205.3205 for a free private consultation with Dr. Darido.

#### Difficulty Swallowing after Gastric Sleeve Surgery
Cynthia from Humble Sent us this question:

“I had Gastric Sleeve & Hiatal Hernia surgery in Nov 2017.  Lots of problems afterwards with food not staying down.  Food still gets stuck in a pouch/bubble & taking Dexilant/Aciphex for acid reflux.  It's recommended that I get the Gastric Bypass surgery to correct the problem... is that a good suggestion?  Thank you!”

Dear Cynthia,

Food not going through gastric sleeve lumen is highly suggestive of gastric sleeve stricture. Gastric sleeve stricture is a narrowing in gastric sleeve lumen that leads to food regurgitation, nausea, vomiting and pain. Gastric sleeve proximal to stricture tends to dilate with time creating a pouch where food accumulates. Gastric sleeve surgery is performed using mechanical stapler. The stomach is resected and stapled over a bougie placed inside stomach lumen. If bougie size is too small a stricture may form. Some bariatric surgeons in Houston oversaw the staple line to prevent bleeding or leaks. This may narrow the lumen. Other causes of gastric sleeve stricture include adhesion formation around stomach or twisting of gastric sleeve.

Upper endoscopy and contrast study are recommended to elucidate the problem. Sometimes, balloon dilation using endoscopy or scar tissue resection is enough to resolve the problem. If the stricture is long and/or severe, conversion of gastric sleeve to gastric bypass is the only way to alleviate obstruction.

Whatever the cause, your symptoms are not normal after sleeve gastrectomy and you don’t need to suffer. Please consult with a competent bariatric surgeon to help you fix the problem and improve your quality of life.

#### Do Hiatal Hernias Fail After Gastric Sleeve Surgery?
Sasha from Kingwood, North Houston, sent us this question: “I had a Bariatric sleeve/hiatal hernia repair in October 2015. I lost 100 lbs. I had severe acid reflux before surgery. It was gone completely after surgery. I had some regain last year but lost 50 lbs. However, my reflux has returned. Medications and a change in eating habits have had no effect. I’m having surgery in May. Drs tell me that 65% of these repairs fail. My question is why did it fail after I lost the weight? It does not make sense. Thank you.”
Dear Sasha,
Properly performed hiatal hernia and sleeve gastrectomy are associated with high acid reflux resolution rate and low failure/recurrence rate. Proper hiatal hernia repair is technically demanding especially in the obese patient with an enlarged liver. Incomplete esophageal mobilization during hiatal hernia invariably results in hiatal hernia recurrence. A second reason for hiatal hernia development leading to acid reflux development is a narrowed gastric sleeve. Narrowing the sleeve lumen at the junction between gastric antrum and gastric body results in functional obstruction. Functional obstruction favors reflux of gastric content into esophagus. Initially, reflux is minimal especially if the hiatal hernia was repaired. Consequently, patients, like yourself, do not experience acid reflux symptoms in the early post-operative period. However, with time constant acid reflux forces the esophagus to retract into the chest leading to hiatal hernia development. Hiatal hernia formation exacerbates acid reflux and acid reflux further contributes to hiatal hernia development. At this point, patients start to experience acid reflux symptoms which tend to worsen with time.
Luckily, gastric sleeve narrowing resulting in functional obstruction resolves with time as the stomach dilates in that area. Hence, Redo hiatal hernia repair is an effective and durable solution to stop acid reflux and alleviate symptoms. If stomach narrowing is still present, unlikely to be your case, then conversion of gastric sleeve to gastric bypass is needed to stop acid reflux.

#### Do UGIs Predict Weight Loss after Sleeve Gastrectomy?
Sleeve gastrectomy is a simple and straightforward surgery to perform. The stomach is mobilized along the greater curvature and cut longitudinally with a linear stapler. The purpose of surgery is to modify the interaction between ingested food and stomach to alter certain neuro-hormonal signals. Signals as Ghrelin, GLP-1 and PYY affect metabolism, appetite, satiety and ultimately result in weight loss. Many bariatric surgeons have difficulty accepting the fact that metabolic surgery is more about altering these neuro-hormonal signals than mechanically restricting the stomach. Consequently, when gastric sleeve surgery was first introduced several years ago, the debate about bougie size dominated our metabolic and bariatric surgery field. Whole sessions in Obesity Week and other bariatric surgery conferences were devoted to discussing the optimal sleeve lumen diameter. The assumption, of course, was that the smaller the bougie diameter the better is weight loss. This assumption was proven wrong. Many published studies have shown that the smaller the bougie size the higher is the leak rate with no improvement in percent excess weight loss.

Knowledge about sleeve gastrectomy mechanism of action, predictors of weight loss and optimal surgical technique is still not established. As John Naisbitt said: “We Are Drowning in Information but Starved for Knowledge”. We will continue to be bombarded by studies that will not advance our practice or improve our skills. This newly published article: “Is a retained fundus seen on postoperative upper gastrointestinal series after laparoscopic sleeve gastrectomy predictive of inferior weight loss?” is a perfect example. It is a single center, retrospective study that includes 149 sleeve gastrectomy patients. Patients were divided into 4 groups depending on the ratio of fundus to more distal sleeve lumen diameter, measured on postoperative upper gastrointestinal series (UGI). The authors found no difference in mean percent excess weight loss at one year following sleeve gastrectomy in all 4 groups. Of note, a single surgeon performed all 149 sleeve gastrectomies using a 34 French bougie. A 1 cm distance from GEJ was left at the angle of His.

I should mention that a postoperative UGI is not an accurate measure of sleeve lumen. The resected stomach is edematous, blood clots may be present along the staple line and sleeve lumen contrast filling is not homogeneous. Accepting this limitation, the study doesn’t show a difference in weight loss even when comparing the most optimally resected gastric fundus to the severely retained fundus. So how much gastric fundus should be resected to achieve the best weight loss? The answer to this question depends on the sleeve mechanism of action. If pure restriction is the dominant mechanism of action then the smaller the sleeve volume the better is weight loss. This however is not the case. Indeed, I preserve most of the antrum to prevent narrowing at the incisura angularis and to maintain the gastric pump that promotes gastric emptying. Most importantly, I preserve the antrum to maintain the Magenstrasse gastric emptying pathway. I believe that sleeve gastrectomy mechanism of action relies on restoring the Magenstrasse pathway of gastric emptying. This allows for rapid delivery of ingested food particles into the distal intestines stimulating the neuro-hormonal signals that result in weight loss. The Magenstrasse emptying pathway depends on antral wave contractions. Accordingly, mutilating the gastric antrum along a 34 French bougie is not necessarily associated with the best weight loss results. Discussing optimal gastric fundus resection in the setting of a resected antrum is not likely to yield any meaningful results. Preserving the antrum and optimally resecting the gastric fundus seem to be the best approach for sleeve gastrectomy. But what is optimal gastric fundus resection? The fundus can be completely resected flush at the GEJ. Part of the fundus may also be left unresected leaving a gastric bubble. At Houston Weight Loss Surgery center, we have found that aggressive gastric fundus resection is not associated with better long-term weight loss results. Rather, aggressive gastric fundus resection results in severe restriction and very limited gastric capacity. Patients typically reports uncomfortable restriction during the first 6 months of surgery without the benefit of increased weight loss. I have learned from observing such patients that mechanical restriction is not the dominant mechanism for weight loss. Excessive restriction following sleeve gastrectomy is not associated with better weight loss. I leave one cm of gastric tissue at the GEJ to prevent narrowing in that area and avoid patient discomfort. I resect most of the posterior gastric fundus by applying proper retraction during surgery. does leaving a larger unresected fundus lead to poor weight loss? The answer to this question maybe a yes but the cause is not poor restriction. Leaving a larger fundus may result in slower gastric emptying and poor Magenstrasse wave formation. Studies are needed to prove or disprove these observations. One thing for sure, we have had plenty of studies demonstrating that mechanical restriction by itself is not the underlying cause for weight loss. Yet, many still believe, like the authors of this article that “restriction is considered to be one of the most important mechanisms for weight loss in stapled procedures”.

#### Do We Have a Cure for Gastroparesis?
Gastroparesis is a poorly understood disease that affects 4% of the population. Unfortunately, there is currently no cure for gastroparesis. Treatment relies on several pro-motility and anti-nausea medications. Medical treatment fails to address the underlying dysmotility problem and is therefore quite ineffective. Gastroparesis patients have limited options and are left most of the time in hopeless situations fighting a disease that affects every single aspect of their daily life. Living with gastroparesis is hard. Coping with symptoms like bloating, pain, nausea, vomiting and inability to tolerate regular food is a daunting task to the strongest of us.

I have had the chance over the past few years to develop a surgical procedure that promotes gastric emptying. The idea behind the procedure is based on several published reports demonstrating increased gastric emptying following sleeve gastrectomy. The exact mechanism of action of increased gastric emptying following gastric sleeve surgery is not well understood. It is partly due to decreased gastric wall compliance. Gastric emptying however, is a highly coordinated process. Several neuro-hormonal signals generated by the stomach and duodenum in response to food intake coordinate stomach emptying. Sleeve gastrectomy alters some of these signals leading to accelerated gastric emptying. Weight loss appears to be a side effect of this altered motility.

For gastroparesis patients, I performed an antrum preserving longitudinal gastrectomy. Around 75% of the gastric fundus and body are resected. The antrum which is the stomach pump is completely preserved. Most gastroparesis patients have a dilated gastric fundus and body and a normal size antrum. The antrum is a thick muscular compartment and is a main contributor to the Magenstrasse gastric emptying. I believe that gastroparesis patients have abnormal Magenstrasse emptying. The modified sleeve gastrectomy I perform restores the Magenstrasse and contributes to improvements in gastric emptying.

All my gastroparesis patients who underwent the modified sleeve gastrectomy have had complete resolution of their symptoms. Some of these patients agreed to undergo a post-operative gastric emptying study that showed normal gastric emptying rate. I operated on 2 obese patients with gastroparesis and advanced type 2 diabetes. I offered these patients a traditional sleeve gastrectomy. I perform an antrum preserving sleeve gastrectomy on all my patients. Preserving the antrum promotes gastric emptying and is associated with excellent weight loss and diabetes improvement. Both patients had complete resolution of their gastroparesis related symptoms. Their post-operative contrast studies demonstrated accelerated contrast emptying from the stomach.

Do we have a cure for gastroparesis? In my limited series of patients, the answer is YES. I think that restoring the Magesntrasse by preserving the antrum, resecting the greater curvature of the gastric body and most of the gastric fundus is an effective, safe, and durable treatment for gastroparesis. A prospective randomized study is needed to establish this approach to help millions of suffering gastroparesis patients all over the world.

#### Do You Suffer from Acid Reflux Following Sleeve Gastrectomy?
It has become a routine to publish at least one article on the effect of sleeve gastrectomy on GERD in the monthly SOARD publication of the American Society of Bariatric and Metabolic Surgery, ASMBS. Acid reflux is threatening to undermine the very low long-term complication rate of gastric sleeve surgery. “Gastroesophageal reflux disease and Barrett’s esophagus after laparoscopic sleeve gastrectomy: a possible, underestimated long-term complication” is a new study by Nicola Basso el al from Rome, Italy. The authors show a significant increase in esophagitis, Barrett’s esophagus and upward migration of the Z line in 110 patients following sleeve gastrectomy performed between 2007 and 2010. Interestingly, they have noticed that most reflux is bilious in nature and describe it in their article as “biliary-like reflux”. The authors report that 14% of the patients underwent a concomitant hiatal hernia repair. They performed what they describe as a “radical fundectomy”. Gastric sleeve resection started at 6 cm from the pylorus and was performed over a 48 F bougie. The staple line was reinforced with a running suture. The gastric remnant measured 60-80 ml, however, the authors do not mention how they measured the gastric sleeve volume.

The most striking finding in this study is the very high incidence of post sleeve gastrectomy GERD related symptoms. All sleeve patients had esophagitis on repeat post-operative EGD and 75% developed Z line migration which in certain cases may represent de-novo hiatal hernia formation. These are the highest reported numbers in the literature and by far, they do not reflect my experience with gastric sleeve surgery. Indeed, when properly performed sleeve gastrectomy resolves pre-existing acid reflux and it prevents the development of de-novo GERD. Hence, is Nicola Basso and colleagues doing something wrong?
The most common cause of post-sleeve gastrectomy GERD is functional narrowing of the incisura angularis. Is it possible that the authors have inadvertently narrowed the incisura angularis? Over sewing the staple line can cause a functional stricture especially when the staple line is too close to the bougie. Adding a “radical fundectomy” and resecting most of the antrum results in a narrow rigid tube that is a recipe for acid and bile reflux. Indeed, when the stomach is mutilated in this a fashion to achieve a “60 to 80 ml” pouch, the tube-like sleeve and the esophagus becomes one continuous cavity that is subject to the negative intra-thoracic pressure. With every breath, the negative intrathoracic pressure is directly transmitted to the sleeve lumen promoting bile reflux into the gastric lumen. Bile and acid accumulate in the proximal stomach above the narrowed incisura. Bile and acid then reflux into the esophagus resulting in severe esophagitis and favoring the development of Barrett’s esophagus. With time, the Z line migrates into the chest favoring the development of a hiatal hernia and the migration of the sleeve into the chest leading to worsening GERD.

When gastric sleeve surgery mutilates the stomach, GERD is an inevitable consequence. I have advocated for a long time, antrum preservation, and a wide incisura angularis (at least 2.5 cm or 75 F). Unfortunately, most bariatric surgeons across the world are driven by the concept of mechanical restriction. Mechanical restriction by itself does not result in durable weight loss. Excessive restriction in the case of sleeve gastrectomy results in GERD. By the same token, inadequate gastric sleeve resection that leaves too much gastric tissue results in poor weight loss. Sleeve resection must be tailored to the stomach shape and must follow basic principles to achieve the most optimal result. Gastric sleeve surgery like any other surgery remains an art with a scientific basis. Mastering the art of sleeve gastrectomy while understanding basic physiology and anatomy can save many patients from unwanted complications.

#### Does Gastric Sleeve Surgery Cause Barrett’s Esophagus?
Felsenreich et al. recently published in the journal of Obesity Surgery a very interesting study on gastric sleeve surgery long-term outcomes. The study is titled: “Update: 10 years of sleeve gastrectomy-the first 103 patients” and includes all patients who had gastric sleeve surgery prior to 2006 at participating bariatric centers in Austria. After more than 10 years, following sleeve gastrectomy, the authors re-examined 44 of 65 non-converted patients using upper endoscopy, manometry, 24-hour pH-metry and questionnaires. They found acid reflux in 57% and Barrett’s esophagus in 14%, (6/44), of gastric sleeve patients. They also found a higher rate of hiatal hernia formation in reflux patients and poorer quality of life on questionnaires. Patients with acid reflux, Barrett’s esophagus and hiatal hernia were previously excluded from having gastric sleeve surgery. Hence, on the basis of these findings the authors implicate gastric sleeve surgery as a refluxogenic procedure and recommend screening endoscopies at 5-year interval after surgery.
Analysis of the results
I agree with the results of this study, but I completely refute the conclusion. There is no doubt that acid reflux causes a hiatal hernia to develop, and bile reflux is a risk factor for Barrett’s metaplasia. Bile reflux is also more likely to occur in the setting of sleeve gastrectomy. The majority of obese patients have at least a sliding hiatal hernia which positions the upper part of the sleeve in close proximity to the negative intra-thoracic pressure. Furthermore, gastric sleeve wall compliance is low. Hence, gastric sleeve lumen easily transmits the negative intra-thoracic pressure across the pylorus into the duodenum. This results in a suction like effect favoring bile reflux from duodenum through gastric sleeve lumen and into the distal esophagus. These findings are the hallmark of a poorly performed gastric sleeve surgery. Poorly performed gastric sleeve surgeries were especially common 10 years ago. The use of a small bougie size to achieve the smallest size gastric sleeve was common practice, and unfortunately still is in certain bariatric centers. Mechanical restriction was the guiding principle to performing an effective gastric sleeve procedure for weight loss. Bariatric surgeons in Houston and across the world, placed a 30 to 32 French bougie along the lesser curvature, and performed a mutilating bariatric procedure that left very little stomach. Such an approach destroyed the gastric anti-reflux barrier. It is commonly assumed that the lower esophageal sphincter is responsible for preventing acid reflux. However, the lower esophageal sphincter is under control of gastric motility. Disrupting gastric motility via an aggressive sleeve resection results in acid reflux, bile reflux, hiatal hernia formation, and Barrett’s esophagus.

At Houston Weight Loss Surgery Center, gastric anatomy and physiology is taking into consideration when performing gastric sleeve surgery. The incisura angularis is not narrowed and hiatal hernias when present (most of the time) are properly repaired. The end result is resolution of pre-existing acid reflux and absence of de-novo acid reflux development. I strongly believe that not all gastric sleeves are created equal. While some gastric sleeve techniques end in acid reflux, others cure pre-existing acid reflux.

Reference

Felsenreich DM, Ladinig LM, Beckerhinn P, et al. Update: 10 years of sleeve gastrectomy-the first 103 patients. Obes Surg. 2018

#### Duodeno-gastric Bile Reflux after Sleeve Gastrectomy
We have previously discussed the pathophysiology associated with bile reflux from duodenum into gastric sleeve lumen ending into distal esophagus in the setting of hiatal hernia. At Houston Weight loss Surgery Center, we have made the observation of increased incidence of bile gastritis in gastric sleeve patients with hiatal hernia and distal esophagitis. We were hoping for large scale studies to be published in the literature to confirm our observations. Unfortunately, we haven’t seen such studies published yet. The recent article in Surgery for Obesity and Related Diseases journal titled “Duodenogastric biliary reflux assessed by scintigraphic scan in patients with reflux symptoms after sleeve gastrectomy: preliminary results” add very little to our observations.

The authors prospectively evaluate 22 gastric sleeve patients with reflux symptoms using scintigraphy and upper endoscopy. From 2014 till 2016, 47 out of 167 sleeve gastrectomy patients developed de novo acid reflux symptoms. Of the 47 gastric sleeve patients with reflux, 36 had esophagitis on EGD and two had Barrett’s esophagus. 22 gastric sleeve patients with reflux symptoms (9 of 22 had no esophagitis on EGD) underwent duodeno-gastric reflux scintigraphy evaluation to check for bile reflux from duodenum into stomach. Only 7 had a positive test (4 out of 7 had no esophagitis). Patients with pre-operative hiatal hernia or acid reflux were not included in this sample. However, there is no mention of hiatal hernia evaluation after gastric sleeve surgery. We know that gastric sleeve patients with acid reflux tend to develop hiatal hernia, also described as sleeve migration into the chest. Authors used a 34 French bougie size during gastric sleeve surgery. Gastric sleeve resection starts 2 to 3 cm close to the pylorus and staple line is reinforced with absorbable sutures.

Study design and small patient size are major flaws in this article that prevent us from drawing any meaningful conclusion. Furthermore, the authors fail to discuss the impact of two important factors, hiatal hernia and narrowing of incisura angularis, on acid and bile reflux development in their patients. They have adopted an aggressive sleeve gastrectomy technique that resect most of the gastric antrum, and narrow the incisura (34 French bougie, and staple line reinforcement). No wonder 30% of their gastric sleeve patients developed de novo acid reflux symptoms. Patients with pre-operative GERD were excluded from this study but I suspect most of these patients continued to have acid reflux symptoms after sleeve gastrectomy. At Houston Weight Loss Surgery Center, we strongly believe that a properly performed sleeve gastrectomy and hiatal hernia repair, cure acid reflux in the majority of bariatric patients. Unfortunately, poor sleeve gastrectomy surgical technique led by the wrong assumption of aggressive resection and maximal mechanical restriction of gastric lumen, invariably results in severe postoperative acid and bile reflux.

Last but not least, bile reflux is more commonly seen in gastric sleeve patients with an unrepaired concomitant hiatal hernia. A narrowed incisura angularis in the absence of hiatal hernia leads to acid reflux in the early post-operative period. Persistent acid reflux results in hiatal hernia formation also known as sleeve migration into the chest. At this stage, the negative intra-thoracic pressure is transmitted though the herniated gastric sleeve lumen into duodenum leading to bile reflux. This observation may explain the negative scintigraphy scan in gastric sleeve patients with de novo reflux symptoms. Unfortunately, the authors did not elaborate on the presence or absence of hiatal hernia on upper endoscopy in this study.

#### Eatfitters: Fresh Food Cooked Daily
Alternatives to fast food are making a mark in the city of Houston. Fresh food, cooked daily and low in salt, sugar and fat is probably the most important contributor to healthy living. You are what you eat. Your health depends on quality nutrition. Your body requires daily healthy meals to heal itself, lower inflammation, prevent cancer and keep the weight under control.
Eatfitters started in 2010 in Houston, preparing meals using fresh and quality ingredients. Eatfitters offer prepackaged meals to take on the go, order online for home delivery or heat and eat right in the restaurant. A nutritionist is available onsite for free evaluation, nutrition advice and answer any diet related question you may have. Eatfitters can work with youon developing a customized diet plan that fits your needs. Whether you are preparing for weight loss surgery or recovering from a gastric sleeve or bypass Eatfitters can meet your demand. There are plenty of options to choose from a diverse menu. Best of all, Eatfitters adopt a no preservative and no additive policy in all their dishes. Sugar and salt are kept at a minimum. So if you are trying to improve your blood pressure or shed few extra pounds Eatfitters is an excellent option.
Proper nutrition can prevent many ailments that plague our modern society. Obesity, sleep apnea, diabetes, cancer, hypertension … all have one root cause in common: Bad nutrition. Our hectic lifestyle prevents us from making good nutrition choices sometimes. Eatfitters is here to help you get back on track. Get involved with your food and eat for life, health and your wellbeing. Visit a local Eatfitter shop. Take a friend or your family and try them out. You will not be disappointed.
Visit Eatfitters at www.eatfitters.com

#### Endoscopic Bariatric Surgery Revision in Houston
Patient A.S. sent us this question: “I had Bariatric Sleeve surgery in Houston, regained my weight back. I had watch a surgeon on you tube perform Endoscopic Sleeve Gastrolatry the advantages of minimal invasive weight loss. I am diabetic Type II, and Obese as of now. Can I qualify for these procedure for a second chance rather than DS-Duodenal Switch. Please Advise. Thank you.”

Dear A.S,

Gastric sleeve revision surgery may be indicated after weight regain. First, a thorough evaluation with a qualified bariatric surgeon is needed to determine the reasons of weight regain. Accordingly, several surgical options for gastric sleeve revision may be offered if you are deemed a good candidate for weight loss surgery. These include redo sleeve resection, conversion of gastric sleeve to gastric bypass or duodenal switch. Redo gastric sleeve surgery is typically offered if the initial sleeve gastrectomy was poorly performed. A retained gastric fundus in the setting of a hiatal hernia is in my experience, at Houston Weight Loss Surgery Center, a common cause for poor weight loss and weight regain. I have had great success in revising these cases by resecting the retained gastric fundus and repairing the hiatal hernia. Patients with gastric sleeve lumen narrowing following sleeve gastrectomy require revision to Roux-en-Y gastric bypass to alleviate the obstructive symptoms like heartburn, regurgitation and vomiting

Gastric sleeve conversion to duodenal switch, DS, is also a viable option especially for super morbidly obese patients with type 2 diabetes. DS is the most effective surgical solution for type 2 diabetes. DS, however, is a malabsorptive procedure and is associated with long-term complications including diarrhea, excessive flatus, vitamin and mineral deficiency, osteopenia, osteoporosis, and kidney stones. If you have advanced diabetes and your BMI is more than 50, DS may be a good option for you.

Endoscopic sleeve gastroplasty is a novel and experimental weight loss procedure. We have limited data on its effectiveness as a primary weight loss procedure. I am not aware of any studies examining the use of endoscopic suturing to revise a failed gastric sleeve. The concept is quite appealing due to its non-invasive nature. Effectiveness and durability must also be taken into consideration. There is no point of using a minimally invasive revision procedure that does not work.

I hope this brief review is of help to you. Warm Regards, Dr. Darido

#### Endoscopic Sleeve Gastroplasty
Endoscopic procedures for treatment of obesity and GERD are flooding the market these days. The FDA has approved a number of devices like TIF and MUSE for GERD treatment and the Intragatric Balloon for weight loss. These devices are introduced as a “bridge” between medical therapy and surgery. They are praised as much needed tools to fill in the “gap” in the treatment of two disease that have reached an epidemic level in our society. Access to surgery is limited for various reasons. Cost and fear of surgery are common barriers between patients and surgical procedures. Along those lines, the newly acclaimed endoscopic sleeve gastroplasty for treatment of obesity is introduced.

Endoscopic sleeve gastroplasty is an outpatient procedure performed through the mouth using endoscopic suturing. It is less invasive than a sleeve gastrectomy and costs much less than traditional laparoscopic surgery. The stomach volume is reduced forcing the patient to eat less. The authors, however, who developed this procedure, claim that it reduces gastric emptying and attributes this fact to promoting satiety and delaying hunger. In their study published in Clinical Gastroenterology and Hepatology, 25 obese patients underwent this procedure with 3 suffering from serious complications including a pulmonary embolus and leak. This is equivalent to 4% leak rate. A very high number when compared to current gastric sleeve or bypass surgery series. Four of the participants were tested for gastric emptying and showed slowing of gastric emptying of solids.

No doubt that this procedure contradicts everything we know about sleeve gastrectomy mechanism of action. Gastric sleeve surgery entails the complete resection of the gastric fundus leading to accelerated gastro-duodenal food emptying. Rapid food delivery to the distal intestine stimulates the secretion of certain gut hormones like GLP-1 that promote satiety, decrease hunger and postprandial blood sugar. Endoscopic sleeve gastroplasty leaves a big part of the gastric fundus un-resected and delays gastric emptying.

Is it possible for two opposing mechanism to lead to weight loss? I seriously doubt it. We invite our gastroenterology colleagues at the Mayo Clinic in Rochester to reconsider their position on means of altering gastric physiology to achieve weight loss. Reorienting their research towards promoting gastric emptying using innovative technology may help millions of obese and diabetic patients worldwide.

#### Endoscopic Sleeve Gastroplasty Under Fire
“Without data, you are just another person with an opinion”, concluded R. Cohen MD his attack and critique of the novel weight loss procedure, endoscopic sleeve gastroplasty also known as Endosleeve. Cohen et al conducted a systemic review regarding the efficacy and safety of endoscopic sleeve gastroplasty. The authors found no supporting scientific evidence to recommend the use of endoscopic sleeve gastroplasty for treatment of obesity in clinical practice.

I agree with Cohen et al that there are no serious studies yet to support endoscopic sleeve gastroplasty as an effective weight loss procedure. The concept of sleeve gastroplasty is itself, however, flawed and makes no sense. Gastric mechanical restriction that does not alter gastro-intestinal neuro-hormonal signals, like lap band procedure, is not an effective and durable weight loss solution. Obesity is a metabolic problem that requires a metabolic procedure to achieve durable weight loss.

Endoscopic sleeve gastroplasty decreases gastric emptying contrary to gastric sleeve surgery and gastric bypass surgery. Increased gastric emptying has been the most important mechanism of action of effective weight loss procedures. Rapid food transit time and increased nutrient absorption across the intestinal surface stimulates the secretion of intestinal hormones like GLP-1 and PYY that promote weight loss and increase satiety. Those in support of sleeve gastroplasty naively believes that food stasis in the stomach increases satiety leading to decreased caloric intake and weight loss. This theory is outdated and no longer valid. Unless, they provide a more logical and reasonable mechanism of action, sleeve gastroplasty proponents ought to reconsider their position.

Weight loss procedure development should no longer be guided by the erroneous concept of mechanical restriction. I developed gastric fundus invagination based on careful analysis of the literature and a number of observations that demonstrate the role of gastric fundus in gastric emptying, satiety and weight loss. The theoretical basis for gastric fundus invagination is solid and hopefully additional studies in the near future demonstrate its effectiveness and safety.

#### ESG or Once Weekly Injection for Treatment of Obesity
In July 2022, two prospective randomized trials were published for two different treatment modalities for class one and two obesity (BMI between 30 and 40). One trial was published in the Lancet journal and the other trial was published in the New England Journal of Medicine. Endoscopic sleeve gastroplasty (ESG), MERIT trial, showed a mean percentage total body weight loss of 13.6% vs 0.8% for control group at 52 weeks. At 72 weeks, once weekly injection of Mounjaro (Tirzepatide) trial showed 15% total body weight loss with 5 mg dose and 20.9% total body weight loss with 15 mg dose vs 3.1% with placebo dose.
Both trials have shown significant weight loss compared to control group with low risk of adverse events. However, there is a major difference between a purely restrictive procedure like ESG and a metabolic treatment like Mounjaro. ESG does not alter gut hormones that are central to weight loss like GLP_1 and PYY. ESG forces you to eat less leading to a calorie deficit or starvation and subsequent weight loss. Mounjaro, a GLP_1 and GIP agonist, decreases your appetite leading to decreased caloric intake and weight loss. Contrary to sleeve gastrectomy, ESG decreases gastric emptying. Thus, it prevents the stimulation of gut hormones that decrease insulin resistance and increase satiety levels. Starvation induced weight loss is never durable. Yet, some researchers and medical companies continue to push stomach restrictive procedures hoping to achieve weight loss. The driving force behind these innovations is not a valid mechanism of action for weight loss but rather an incisionless procedure that appeals to millions of patients who are apprehensive of minimally invasive surgery.
Mounjaro is more effective and less invasive than endoscopic sleeve gastroplasty. Pharmaceutical companies are winning the race for obesity treatment against endoscopic procedures. Medications like Mounjaro and Ozempic partially mimic the effect of reliable metabolic procedure like sleeve gastrectomy and gastric bypass. Endoscopic sleeve gastroplasty mimics the restrictive effect of Lap Band surgery. Gastric banding is no longer performed because of poor outcome. However, those of us who fail to learn from history are doomed to repeat it !!

#### Fall in Love… with Vegetables
It’s fall time in Houston. The hot summer days are gone and a cool autumn breeze is filling the air. Thanksgiving is around the corner, and pumpkins are everywhere. Pumpkins, however, are not the only vegetable this season. Squash, kale, beets, brussels sprouts, cauliflower, cabbage, parsnips … abound when fall comes around. These tasty vegetables are rich in antioxidants, minerals, vitamins and fiber. Beets contain betalain, a phytonutrient with antioxidant and anti-inflammatory benefits. Brussels sprouts contain glucosinolate compounds that help fight cancer. Kale is rich in vitamin K and A and helps lower cholesterol.
Houston Weight Loss Surgery Center recommends incorporating seasonal vegetables in your daily diet. Many studies show that vegetables can reduce your risk of developing heart disease and cancer. Another great benefit of vegetables is their low calorie count. Vegetables can fill you up without breaking your calorie bank. Try having meatless meals several times a week. Replace processed food and frozen meals with fresh and local vegetables picked at the peak of their nutritional value. Get out of your comfort zone and taste different vegetables. Don’t buy the same kind of vegetable each time. Learn how to cook vegetables in a variety of ways with different spices. Pureed boiled or steamed vegetables make delicious soups. Add them to your homemade broth for a nutritious meal after gastric sleeve or gastric bypass surgery. Grilled vegetables are a great BBQ alternative to fatty cuts of meat. Try placing onions, squash and zucchini on a skewer next time you fire up the grill. You will be amazed by the taste. Quarter your favorite vegetables then toss them in olive oil with salt, crushed pepper, and herbs like rosemary and thyme. Place in an oven and roast for 30 minutes until browned and tender. This is my favorite way to prepare brussels sprouts.
Last, I would like to remind you to enjoy the cool weather and go out for evening walks in nature.

#### For The First Time In Human History: Obesity Rates Trump Underweight Numbers In A Worldwide Analysis
Magid Ezzati is the leading author of a recent article published in Lancet. The study is titled “ Trends in adult body-mass index in 200 countries from 1975 to 2014: a pooled analysis of 1698 population-based measurement studies with 19·2 million participants”. The objective of this analysis involving around 200 countries is to analyze the worldwide trends in body weight over the past 40 years. The purpose of the analysis is to help public health policy makers develop strategies and implement policies to curb the obesity epidemic.

Dr. Ezzati, from the School of Public Health at Imperial College London in the United Kingdom, alarmingly concluded that if present trends continue, not only will the world not meet the World Health Organization obesity target of halting the rise in the prevalence of obesity, but more women will be severely obese (BMI greater than 35) than underweight by 2025. In 2014, about 266 million men and 375 million women were obese in the world, compared with 34 million men and 71 million women in 1975.

It is interesting to notice that results vary widely across countries. For instance women in Singapore, Switzerland, Japan, the Czech Republic, Belgium, and France had almost no increase in average BMI (less than 0.2 kg/m² per decade) over 40 years. On the other hand, more than one in four severely obese men (27.8%) and 18.3% of severely obese women in the world live in the United States. Public health officials ought to look at these numbers and start implementing new policies to control this epidemic. Bariatric surgery is currently the only effective treatment for obesity. However, in the United States only 1% of the severely obese patient population undergoes weight loss surgery every year. Obese individuals are contributing to skyrocketing rates of type 2 diabetes, hypertension, gastro-esophageal reflux disease, cancer…These rising trends are starting to affect our life expectancy as a society. New reports from the CDC are showing a rise in age-adjusted death rate for the first 9 months of 2015 compared to the same period in 2014. Stroke, diabetes and heart related disease have most notably increased. These obesity related problems would lead to dramatic consequences in health care. From a financial point of view, the cost of taking care of obesity related comorbidities have reached an astronomical level of 200 billion dollars per year in the US alone. By 2020, the cost of diabetes care alone may reach 500 billion dollars. Bariatric surgery by itself is not a solution for the billions of obese individuals all over the world. Dr. Ezzati explains that people living in countries like France and Switzerland are more likely to eat fresh and unprocessed food and to eat in moderation. Other lifestyle related factors are also at play and must be analyzed and implemented through public health policies. Prevention of weight gain should be the guiding principle. Individuals, families, communities, towns and countries must emulate a healthier lifestyle than what we currently have. For these lifestyle changes to take effect the US government must intervene to change the food environment. For today’s food environment exploits people’s biological, psychological, social, and economic vulnerabilities, making it easier for them to eat unhealthy foods… Currently, in the US, government intervention is hampered by a complex array of obstacles: Personal freedom, food industry lobby, food advertising laws, access to fresh produce… Meanwhile, the burden of obesity according to Dr. Ezzati will continue to rise unabated across the world. Today, we urgently call for regulatory actions from government along with full  cooperation from industry and society to overcome the obesity epidemic.

#### From Bariatric to Metabolic Surgery… A Field in Evolution
Our understanding of obesity and weight loss surgery mechanisms of action has rapidly evolved over the past few years. From the naïve assumptions of restriction and malabsorption to the discovery of complex gut centered neuro-hormonal signaling pathways, bariatric surgery has swiftly evolved into the field of metabolic surgery. The dramatic metabolic responses secondary to surgical manipulation of the gastro-intestinal system were difficult to ignore. The failure of purely restrictive procedures, like adjustable gastric banding, to improve blood sugar and insure durable weight loss is now solid evidence. Unfortunately, the demise of such procedures has taken many years. Many patients were lured into a safe and simple procedure only to end up with disappointment, failure and frustration. Massive esophageal dilations, hiatal hernias, aspiration pneumonias, esophageal dysmotility, band erosion and slippage are still common occurrences among many gastric band patients in Houston.
The lessons we have learned from adjustable gastric banding are numerous. First, an obese patient cannot be forced to loose weight. Second, creating a restriction or obstruction or narrowing at he gastro-esophageal junction does not lead to weight loss but to esophageal motility loss. Third, applying pressure over the esophageal fat pad area does not control appetite. Fourth, vomiting and starvation do not lead to permanent weight loss.
Beyond mechanical restriction, we have noticed a rapid blood sugar improvement following gastric bypass and gastric sleeve. Type 2 Diabetes resolution is shortly becoming a primary indication for metabolic surgery. There are now 11 randomized controlled studies favoring surgery over medical treatment of type 2 diabetes. Metabolic surgery is no longer limited to weight reduction. Rather, gastric sleeve or bypass surgery will soon be acknowledged as first line treatment for type 2 diabetic patients including those with BMI lower than 35.
The definition of type 2 Diabetes is changing from insulin resistance due to fat accumulation in muscle and adipose tissue and pancreatic failure to increase insulin secretion, to a gastro-intestinal disorder. Otherwise, how can one explain the improvement in blood sugar following gastric bypass or gastric sleeve surgery before any significant weight loss? It is safe to assume that diabetes starts in the gut. At this early stage, blood sugar is still within normal but GLP-1 secretion is diminished. Metabolic surgery restores GLP-1 secretion independent of weight loss. In fact, postoperative increase in GLP-1 levels contributes to weight loss. Why and how do GLP-1 and other neuro-hormone secretion change after metabolic surgery remain to be elucidated. It is interesting to note that only the post-prandial GLP-1 level changes. Fasting levels remain the same before and after surgery. Hence, we conclude that metabolic surgery changes the interaction between the gut and ingested food. The nature of this interaction is not well understood. One aspect of this interaction relates to gastric emptying. The stomach is a complex endocrine organ. It controls intestinal motility and function by various neuronal and hormonal pathways. It analyzes the content of ingested food and sends a number of signals to the brain, liver, pancreas and intestine. Squirts of ingested food are delivered to the duodenum in a coordinated fashion to stimulate GLP-1 among other neuro-hormones to signal the pancreas, liver and other organs to prepare for the influx of nutrients across the intestinal wall. Gastric emptying is a complex process to say the least. Both gastric bypass and gastric sleeve alter gastric emptying. Both procedures either bypass or eliminate the gastric fundus that plays an important role in gastric emptying. Interestingly, the gastric fundus secretes both Ghrelin and Leptin two important metabolic hormones. Understanding the mechanism of action of metabolic procedure boils down to figuring out the interaction between gastric fundus and ingested food. If the interaction results in the appropriate neuro-hormonal secretion, the body is able to handle absorbed nutrients like glucose. If the interaction is disrupted, several downstream issues arise leading disrupted insulin secretion and function. The end result is weight gain and impaired glycemic control leading to overt type 2 Diabetes.
From this perspective, type 2 Diabetes becomes a gastro-intestinal disorder. Metabolic surgery effectively targets the root cause of type 2 Diabetes. Future investigations will unravel these mechanisms and allow us to develop less invasive surgeries like gastric fundus invagination and possibly more effective medications for treatment of diabetes and obesity.

#### G-POEM for Gastroparesis Treatment
I read with great interest this study by Khashab MA et al, titled “Gastric per-oral endoscopic myotomy (POEM) for refractory gastroparesis: results from the first multicenter study on endoscopic pyloromyotomy” and published in the journal of Gastrointestinal Endoscopy. The authors analyze the outcome of endoscopic pyloromyotomy in 30 patients with refractory gastroparesis.

The technique is adopted from POEM procedure used for achalasia treatment. It is an endoscopic intra-mural approach to cutting the pyloric sphincter muscle in hope of promoting gastric emptying. This approach while appealing and apparently feasible is not likely to improve gastroparesis. The authors, however, report that around 80% of patients had improvement or normalization of their gastric emptying rates.

Gastroparesis is a poorly understood gastro-intestinal motility disorder with no clear treatment guidelines. Drainage procedures in the form of a pyloroplasty or gastro-jejunostomy rarely works. Unless gastric motility is partially or completely restored, physical drainage of gastric lumen by widening the gastric outlet is unlikely to resolve symptoms.

We have developed a laparoscopic procedure that entails resecting the greater curvature of the stomach while preserving the antrum for treatment of severe refractory gastroparesis. The procedure is similar to a sleeve gastrectomy and does not alter gastric outlet size or function. Our success rate has been very high in our series of 10 patients. It is possible to restore gastric motility by resecting the greater curvature. Endoscopic procedures are quite attractive. If, however, they don’t make sense from a pathophysiologic point of view, they are not likely to work. There is a general trend these days to rapidly adopt new endoscopic approaches. Endoscopic surgery is least invasive but not necessarily most effective. G-POEM while feasible and safe is not likely to be a solution for gastroparesis.

#### Gastric Band Conversion to Sleeve Gastrectomy
Adjustable gastric banding, a purely restrictive procedure, is rarely performed these days. However, few years ago, it was a commonly performed procedure. Many Lap Band patients present to our Houston Weight Loss Surgery Center for revision surgery. Some have gastric band related complications like GERD or band erosion, while others have failed to lose weight. Conversion of lap band to gastric sleeve or bypass procedure for failure to lose weight is recommended and is associated with excellent weight loss outcomes. However, concomitant removal of gastric band and sleeve gastrectomy has been associated with increased leak rate in many studies. Consequently, I have always recommended to my patients to stage the procedure. At Houston Weight Loss Surgery Center, we prefer to remove the band first, and after 3 to 6 months perform a gastric sleeve surgery. This month, a new publication in SOARD, titled “Concomitant removal of gastric band and sleeve gastrectomy: analysis of outcomes and complications from the ACS-NSQIP database”, confirms our practice guidelines. The study included 11546 patients who underwent a sleeve surgery between 2010 and 2012. Of those patients, 357 (3%) had a concomitant band removal and sleeve gastrectomy. After multivariate analysis was performed, the odds of developing staple line leak were significantly higher in the concomitant band removal/sleeve gastrectomy group compared to primary sleeve gastrectomy patients (OR=3.81). There was no difference in mortality or rate of return to the operating room.

The study clearly confirms that staple line leak is higher in one stage lap band revision surgery to gastric sleeve. The authors did not analyze band conversion to gastric bypass leak rate and did not include two-stage revisional surgery data. Nonetheless, this article further supports our approach to band conversion to sleeve. There is no doubt in my mind that the safest approach is to stage the revision or revise the band to gastric bypass in one operation.

#### Gastric Bypass and Sleeve Gastrectomy Revision Surgery
I read with great interest the study published in Surgery for Obesity and Related Diseases by DeMaria et al. It is a retrospective review of 96 gastric bypass patients who underwent conversion of to distal gastric bypass between 2010 and 2016. The Roux or alimentary limb is cut at the jejuno-jejunostomy and transposed distally leaving a common channel between 150 to 200 cm in length. The initial 11 patients developed significant diarrhea and protein malnutrition prompting the authors to lengthen the common channel by 100 to 150 cm for the rest of the patients. The mean BMI at initial gastric bypass was 48, and 41 at distalization. At one year after revision surgery Mean BMI dropped to 34 in 42 patients that followed up one year after surgery. At 2 years, BMI was 33 in 18 patients and at 3 years, BMI dropped to 32 in 10 patients. Obviously, patient follow up is a major limitation of this study. Nonetheless, there is a significant drop in excess weight at least in the short-term period following surgery.

Weight regain following gastric bypass surgery is unfortunately not infrequent. The most cause of weight regain following successful gastric bypass surgery is the resumption of processed food consumption high in simple sugars. Patients reports increased hunger, decreased restriction and low satiety levels. Laparoscopic or endoluminal procedures that narrow gastric pouch outlet or decrease its size are associated with high failure rates. After all, gastric bypass surgery is a metabolic procedure. Weight loss following gastric bypass surgery results from altered gastrointestinal neuro-hormonal signals like GLP_1 and PYY rather than mechanical restriction of gastric volume. Distalization procedures aim at bypassing damaged proximal neuroendocrine cells and target more distal cells in the ileum. Distal neuroendocrine cells are assumed to be undamaged by chronic simple sugar consumption like proximal cells. Consequently, distalization procedures can salvage a failed gastric bypass procedure by re-stimulating post-prandial GLP-1 and PYY production. Unfortunately, there are no quality studies addressing these theoretical claims to prove such an approach. It would have been quite informative if the authors of this study checked postprandial levels of GLP-1 and PYY prior to distalization and compared them to postoperative hormone levels and then correlate with weight loss outcomes. Such studies can answer important questions on patient selection and the effectiveness and reliability of revision weight loss surgery. This is equally important for sleeve gastrectomy patients. Weight regain or failure to lose weight following gastric sleeve surgery is a difficult problem to manage. Sleeve conversion to gastric bypass is associated with low morbidity and mortality but weight loss outcomes are not the best. Few studies in the literature address this issue and are limited by small sample size. Unless we understand the neurohormonal changes associated with weight loss and weight gain following metabolic surgery, and we develop reliable tools to measure these changes, revision weight loss surgery is still limited in efficacy and reliability.

#### Gastric Bypass Long-term Complications
Gastric Bypass Long-term Complications

I am a 64 y/o female, 20 years post roux-en-y gastric bypass. I have GERD, a “small” hiatal hernia, Barrett’s esophagus, nighttime bile regurgitation, and bilious vomiting after any decent sized meal. I continue to get worse each year. My GI doctor does not believe it is possible for a gastric bypass patient to have GERD. He believes I simply misunderstand the meaning of GERD. I am so frustrated and miserable. Where should I go from here?

Dear Deborah,

GERD is possible but not likely in gastric bypass patients. At Houston Weight Loss Surgery Center, I treat around 5 gastric bypass patients a year with newly diagnosed GERD. Almost all gastric bypass patients with GERD that I have treated have Barrett’s esophagus. Barrett’s esophagus does not develop in the absence of GERD and is a strong indicator of advanced reflux. Barrett’s esophagus is likely to develop secondary to bile reflux especially in the setting of gastric bypass since there is minimal acid production in the small gastric pouch. In your case, the likelihood of bile reflux is high since you report bilious vomiting and regurgitation.

My recommendations for you is to get evaluated by an experienced reflux specialist and bariatric surgeon. An upper endoscopy and UGI contrast study will help your bariatric surgeon evaluate the anatomy of gastric bypass, check the size of hiatal hernia, measure the length and diameter of the Roux limb and rule out a gastro-gastric fistula. Abnormal gastric bypass anatomy that favors bile reflux includes a short Roux limb or narrowed jejuno-jejunostomy outflow channel. A gastro-gastric fistula develops when the staple line between the gastric pouch and stomach remnant breaks down. A connection between both gastric pouches favors acid and bile passage into the gastric pouch and up into the esophagus. Additional testing may be requested like a CT scan of abdomen and pelvis to rule out an internal hernia causing partial obstruction and favoring bile reflux. Depending on the etiology of your GERD, a solution can be offered.

It is hard to live with daily reflux and vomiting. It is obvious that you have a problem and it is definitely not normal to have such symptoms with gastric bypass. You need help.

#### Gastric Bypass Surgery Is Not a Good Option for Gastroparesis
I was asked to review a study titled “Laparoscopic Treatment of Gastroparesis: A Single Center” submitted for publication in SOARD (Surgery for Obesity and Related Diseases). It is a single center, retrospective study. The charts of 93 patients with either idiopathic or diabetic gastroparesis were reviewed over a period extending from 2003 till 2014. Most patients were treated with gastric electric stimulator implantation. 15 patients underwent Roux-en-Y gastric bypass surgery.

The authors showed that gastric bypass surgery unlike gastric electric stimulation is not associated with statistically significant improvement in vomiting and pain. They also showed that 40% of operated patients continued to use an antiemetic and or pro-kinetic medication after either gastric bypass or gastric electric stimulation. 18% of patients required reoperation. Most of those patients underwent gastric electric stimulator removal. The authors conclude that surgery is feasible and effective for gastroparesis treatment. Although both procedures have some degree of efficacy, Gastric Electric Stimulation seems to provide improvement of more gastroparesis symptoms.

Gastroparesis incidence is rising and we still don’t have a good understanding of its pathophysiology. Most importantly, there is no established effective treatment guidelines for gastroparesis. Many gastroparesis patients are left untreated or poorly treated with symptoms that significantly diminish their quality of life and overall health. 

Randomized, prospective controlled studies have clearly shown that gastric electric stimulation showed no symptom improvement in gastroparesis patients. RYGB is not well studied for gastroparesis treatment. In my personal experience, I have seen no improvement of gastroparesis symptoms following RYGB especially in severe and medically refractory cases.

I disagree with the author’s conclusion stating that gastric bypass and electric stimulation are effective surgical solutions for gastroparesis. According to this study, gastric bypass did not alleviate vomiting and pain and gastric electric stimulation, GES, showed symptom improvement in around 60% of patients. GES and gastric bypass procedures have therefore limited efficacy in gastroparesis management.

I think it is very important for general and bariatric surgeons to understand that gastric bypass surgery is not a good option for medically refractory gastroparesis cases. I have developed a procedure for treatment of gastroparesis, few years ago, based on published reports showing improved gastric emptying following gastric sleeve surgery. A longitudinal gastrectomy or modified sleeve gastrectomy that preserves the gastric antrum (stomach pump) and leaves some gastric fundus (especially for the malnourished patients) has been amazingly effective for gastroparesis treatment in my private practice. I have used this approach in around 10 patients with great results. These patients had complete resolution of all gastroparesis related symptoms including nausea, vomiting and abdominal pain. Any outcome short of complete symptom resolution should not be labeled as “effective”. 

Resecting the greater curvature while preserving the gastric antrum has a real potential for being a breakthrough treatment for this poorly understood disorder. Prospective randomized studies evaluating the modified sleeve gastrectomy for gastroparesis treatment are needed to help us improve our care of this medical condition.

#### Gastric bypass, Gastroparesis, Sleeve Gastrectomy
Question from Tonya in Clear Lake:

“A bariatric surgeon told me I might be a candidate for RYGB, but it depends on my transit times for the smart pill. If I have gastroparesis with delayed gastric and large intestinal transit but normal small intestine am I a good candidate for gastric bypass surgery?”

Dear Tonya,

My experience is limited to gastroparesis and delayed gastric emptying. For patients with severe gastroparesis, I prefer a modified sleeve gastrectomy over gastric bypass to improve gastric emptying and effectively resolve gastroparesis related symptoms. Sleeve gastrectomy improves both gastric and intestinal emptying. Therefore, I predict that a modified sleeve gastrectomy improves intestinal motility too. I am not sure about the effect of gastric surgery on colon emptying. I am also not sure about the clinical significance of small bowel transit time in the setting of gastroparesis.

For patients with delayed gastric emptying but normal small intestine motility, will gastric bypass surgery be equally effective to modified sleeve gastrectomy in alleviating gastroparesis related symptoms? This is a very interesting question and I am not sure if we have an answer. Gastroparesis is a heterogeneous disorder with many different subtypes. Unlike longitudinal gastrectomy or modified sleeve gastrectomy, gastric bypass or resection does not address the underlying pathophysiology of gastroparesis. For this reason, most gastroparesis patients do not respond to either gastric bypass or gastric resection.

To summarize, in my own personal and limited experience, modified sleeve gastrectomy is the best treatment for severe refractory gastroparesis independent of small bowel transit time. There may be a role for gastric bypass surgery in gastroparesis patients with “normal” small bowel motility, but I am not aware of studies to support such an approach.

#### Gastric bypass, Gastroparesis, Sleeve Gastrectomy
Question from Tonya in Clear Lake:

“A bariatric surgeon told me I might be a candidate for RYGB, but it depends on my transit times for the smart pill. If I have gastroparesis with delayed gastric and large intestinal transit but normal small intestine am I a good candidate for gastric bypass surgery?”

Dear Tonya,

For patients with severe gastroparesis, I prefer a modified sleeve gastrectomy over gastric bypass to improve gastric emptying and effectively resolve gastroparesis related symptoms. One study has shown that sleeve gastrectomy improves both gastric and small intestine emptying. Therefore, I predict that a modified sleeve gastrectomy improves intestinal motility too. I am not sure about the effect of gastric surgery on colon emptying. I am also not sure about the clinical significance of small bowel transit time in the setting of gastroparesis.

For patients with delayed gastric emptying but normal small intestine motility, will gastric bypass surgery be equally effective to modified sleeve gastrectomy in alleviating gastroparesis related symptoms? This is a very interesting question and I am not sure if we have an answer for. Gastroparesis is a heterogeneous disorder with many different subtypes. Unlike longitudinal gastrectomy or modified sleeve gastrectomy, gastric bypass or resection does not address the underlying pathophysiology of gastroparesis. For this reason, most gastroparesis patients do not respond well to either gastric bypass or gastric resection.

To summarize, in my own personal and limited experience, modified sleeve gastrectomy is the best treatment for severe refractory gastroparesis independent of small bowel transit time. There may be a role for gastric bypass surgery in gastroparesis patients with “normal” small bowel motility, but I am not aware of studies to support such an approach.

#### Gastric bypass, Gastroparesis, Sleeve Gastrectomy
Question from Tonya in Clear Lake:

“A bariatric surgeon told me I might be a candidate for RYGB, but it depends on my transit times for the smart pill. If I have gastroparesis with delayed gastric and large intestinal transit but normal small intestine am I a good candidate for gastric bypass surgery?”

Dear Tonya,

For patients with severe gastroparesis, I prefer a modified sleeve gastrectomy over gastric bypass to improve gastric emptying and effectively resolve gastroparesis related symptoms. One study has shown that sleeve gastrectomy improves both gastric and small intestine emptying. Therefore, I predict that a modified sleeve gastrectomy improves intestinal motility too. I am not sure about the effect of gastric surgery on colon emptying. I am also not sure about the clinical significance of small bowel transit time in the setting of gastroparesis.

For patients with delayed gastric emptying but normal small intestine motility, will gastric bypass surgery be equally effective to modified sleeve gastrectomy in alleviating gastroparesis related symptoms? This is a very interesting question and I am not sure if we have an answer for. Gastroparesis is a heterogeneous disorder with many different subtypes. There may be a role for gastric bypass surgery in some gastroparesis patients with “normal” small bowel motility, but I am not aware of studies to support such an approach. In my own personal and limited experience, I have had great success with the modified sleeve gastrectomy for treatment of severe refractory gastroparesis.

#### Gastric Electric Activity and Sleeve Gastrectomy
I read with great interest this new study published by O’Grady el al in Obesity Surgery journal and titled “Patterns of Abnormal Gastric Pacemaking After Sleeve Gastrectomy Defined by Laparoscopic High-Resolution Electrical Mapping”. The authors attempt to study gastric electric activity following resection of the greater curvature in gastric sleeve surgery patients. Gastric pacemaker cells also known as the cells of Cajal are in higher concentration along the greater curvature. The cells of Cajal are also distributed throughout the gastrointestinal tract including the esophagus, small intestine, colon and pancreas. There are different types of cells of Cajal and each type plays a different role. Some generate intrinsic electrical rhythmicity in smooth muscle cells and others have mechano-receptor properties. They play a role in coordinating gastro-intestinal motility and their absence or dysfunction is associated with gastrointestinal disorders like irritable bowel syndrome, gastroparesis, achalasia, and hypertrophic pyloric stenosis. Gastrointestinal motility is a complex and highly regulated process that remains poorly understood. Gastrointestinal motility is crucial to life and several diseases like obesity, type 2 diabetes and gastroparesis are associated with gastrointestinal dymotility. Several studies have demonstrated that gastric emptying is accelerated following sleeve gastrectomy. We have taken this finding and applied to several gastroparesis patients. By performing a modified sleeve gastrectomy that preserves the gastric antrum and resects the gastric fundus, we demonstrated an increase in gastric emptying. The underlying mechanisms of such observations are not understood. However, it appears that by resecting the pacemaker cells of Cajal along the greater curvature gastric emptying increases. There is strong agreement in the literature that the cells of Cajal generate gastric slow wave depolarizations. Gastric slow waves can be measured using electric mapping.

In this article, O’Grady attempts to evaluate the effect of gastric sleeve surgery on gastric slow-wave pacemaking using laparoscopic high-resolution electric mapping. Mapping was performed on 8 patients before and after gastric sleeve resection. Slow wave activity parameters included propagation pattern, frequency, velocity, and amplitude. The authors show that the wave velocity significantly increased following gastric sleeve surgery whereas the frequency and amplitude remained unchanged. 50% of the patients developed a distal unifocal ectopic pacemaker with retrograde propagation. The remaining 50% showed no electrical activity. The significance of these findings is unknown. Do patients with bioelectrical quiescence following sleeve gastrectomy loose less weight than those with accelerated retrograde slow wave propagation? Is accelerated retrograde slow wave propagation associated with increased incidence of postoperative GERD? What happened to gastric slow wave propagation one year after surgery and is weight regain following sleeve gastrectomy associated with changes in gastric bioelectric activity?

Understanding gastrointestinal motility and its underlying bioelectrical activity is crucial to elucidating the pathophysiology of many diseases like obesity, type 2 diabetes and gastroparesis. These healthcare issues affect millions of people worldwide. New noninvasive, accurate and sensitive testing modalities need to be developed to evaluate gastrointestinal bioelectric activity in health and disease.

#### Gastric Emptying after Sleeve Gastrectomy
I read with great interest the new study: “Mechanisms of esophageal and gastric transit following sleeve gastrectomy” by Burton et al that was recently published in the journal of Obesity Surgery. 26 patients underwent gastric nuclear scintigraphy, high resolution manometry and barium contrast studies following sleeve gastrectomy. Sleeve gastrectomy was performed over a 36 French bougie starting 4 cm from the pylorus. The staple line was then imbricated with a running suture. There is no mention of hiatal hernia repair. Selected patients did not have significant reflux symptoms. “Significant” was not defined by the authors.

Nuclear scintigraphy showed increased incidence of triggered deglutitive reflux from distal to proximal esophagus in post sleeve gastrectomy patients in comparison to obese controls. This pattern is commonly seen in esophageal outflow obstruction. Rapid gastric emptying from sleeve into small bowel was noted as expected. More interestingly, the authors found a co-dependent emptying pattern between esophagus and stomach. in other words, esophageal emptying and motility contributed to gastric emptying. Typically, esophageal and gastric emptying are two separate processes.

Stress barium studies showed rapid flow of thin barium within a narrow gastric tube into duodenum as expected. The authors describe a cyclical filling and emptying pattern of gastric sleeve vertical and horizontal components. They report filling of vertical component, distention and then emptying into the horizontal component through incisura angularis opening. The horizontal component or what is left of the antrum, contracts as a reflex due to distention then rapidly delivers content into duodenum. Multiple reflux events were noted from sleeve into esophagus during this emptying cycle.

Esophageal manometry showed evidence of sliding hiatal hernia in 50% of the patients. Increased proximal intragastric pressure was noted following a swallow with concomitant prolongation of lower esophageal sphincter contraction. During this phase, contrast moves across incisura into antrum. This is followed by lower esophageal sphincter relaxation and reflux into proximal esophagus. Subsequently, an esophageal contractile wave is generated flushing refluxate back into stomach. This esophageal contractile wave contributes to increased proximal gastric pressure and subsequent gastric emptying across incisura angularis and then across pylorus into duodenum.

There is no doubt that gastric sleeve surgery disrupts esophago-gastric motility and food transit. This disruption is the basis for altered neuro-hormonal signaling leading to weight loss. By the same token, this disruption may lead to worsening or de-novo acid reflux disease with aggressive gastric sleeve resection and restriction. The art of gastric sleeve surgery is to optimize gastric sleeve resection in order to maximize weight loss and minimize acid reflux. Unfortunately, the guiding principle of maximal mechanical restriction has led to stomach mutilation and loss of function. For instance, starting gastric sleeve resection at appoint 4 cm from pylorus destroys the antrum. The antrum is the gastric pump and antral function is crucial to gastric emptying. Eliminating the gastric antrum reduces the stomach to a rigid immotile tube. Furthermore, using a small caliber bougie narrows the incisura angularis and results in functional obstruction to flow between the horizontal and vertical components of stomach. Functional obstruction results in acid reflux, proximal stomach pressurization and the cycling pattern of emptying as it was eloquently described in this paper.

I have always advocated a non-mutilating resection of stomach to achieve the perfect gastric sleeve. Such an approach preserves the antrum, maintains a widely open incisura angularis and eliminates most of the gastric fundus and gastric body without narrowing gastric sleeve lumen. The purpose of gastric sleeve surgery is to favor gastric emptying along the Magenstrasse pathway rather than destroy stomach function and anatomy. If the authors repeat their study on my gastric sleeve surgery patients, I would expect different outcomes and motility patterns. I don’t see de-Novo or worsening acid reflux following sleeve gastrectomy at Houston Weight Loss Surgery Center. On the contrary, acid reflux resolved after sleeve gastrectomy in my practice. The motility patterns the authors are describing are highly suggestive of functional narrowing of incisura angularis. Their surgery technique involves a small caliber bougie and aggressive rection of gastric antrum. To make things worse, the staple line is oversewn further narrowing gastric lumen. This excessive restriction is unnecessary. It transforms the stomach into a rigid tube and a barrier against esophageal emptying: a recipe for acid reflex. Over time, chronic pressurization of proximal stomach and constant reflux results in a weaker lower esophageal sphincter, decreased peristaltic wave pressure, and hiatal hernia development. The result is worsening acid reflux and progressive dilation of gastric sleeve lumen. Dilation of gastric sleeve lumen helps alleviates functional obstruction at the incisura angularis. However, acid reflux persists because of hiatal hernia development and esophageal dysmotility. Repairing the hiatal hernia at this stage has resulted in acid reflux resolution in more than 90% of patients presenting to Houston Weight Loss Surgery Center.

#### Gastric Leptin and The Feeling of Fullness after Metabolic Surgery?
Appetite control is a major factor when it comes to successful weight loss. Hunger is a powerful built in survival drive controlled by the brain. It is difficult if not impossible to subdue your hunger using will power. Many neuro-hormonal signals contribute to a delicate hunger-satiety balance. Among these hormones are ghrelin and leptin, both secreted by the gastric fundus.

The gastric fundus is the ballooning upper part of the stomach. Metabolic surgery like gastric sleeve and gastric bypass procedures are centered on gastric fundus anatomy, structure, and function. Indeed, the gastric fundus is either resected like in gastric sleeve surgery or bypassed in the case of Roux-en-Y gastric bypass procedure. Metabolic surgery is the surgical manipulation of a seemingly normal organ to achieve a biologic effect. When it comes to weight loss, the gastric fundus seems to be that organ. Made of thin, high compliance wall, the gastric fundus stretches following food intake to accommodate a meal. Gastric fundus is well known as a major site for ghrelin synthesis and secretion also known as the hunger hormone. Interestingly, leptin, a satiety hormone, is also secreted by the gastric fundus. Contrary to initial reports, leptin is not only secreted by white adipose tissue. Several studies have shown that leptin is rapidly secreted by gastric fundus glands in response to food intake. Animal experiments have shown a rapid rise in serum leptin levels in response to re-feeding with a concomitant decrease in gastric intracellular leptin levels. Interestingly, leptin is secreted into the gastric lumen bound to a soluble leptin receptor to protect it from proteolysis. The leptin receptor complex empties with gastric content into the duodenum where it attaches to a duodenal enterocyte transmembrane leptin receptor. The complex is trans-cytosed by the enterocyte and moved from the luminal to the basal membrane. At this level, leptin is absorbed into the blood circulation and reaches the hypothalamus to increase satiety, and metabolism independently of adipocyte secreted leptin. Furthermore, leptin act locally in a paracrine fashion and affects nutrient absorption, and intestinal motility.

Gastric leptin favors satiety and weight loss. However, commonly performed bariatric procedures like gastric sleeve and Roux en Y gastric bypass surgery eliminate the role of gastric leptin. This observation has led me to think about leptin secretion preservation following weight loss surgery. What is the potential effect of leptin secretion on short-term and long-term weight loss following a metabolic procedure? Probably for weight loss surgery that bypasses the duodenum like a duodenal switch and gastric bypass procedure, postop gastric leptin secretion most likely has no role. However, for gastric sleeve surgery, the duodenum is preserved. Gastric emptying is accelerated following sleeve surgery but ingested food and other gastric content still interacts with duodenal mucosa. As a result, leptin elimination following gastric sleeve may decrease the amount and durability of post-operative weight loss. A metabolic procedure like gastric fundus invagination, GFI, reduces gastric fundus size, improves gastric emptying, decreases ghrelin secretion but preserves leptin synthesis, secretion into the gastric lumen and interaction with the duodenal mucosa. Preserving leptin function in metabolic procedures that do not bypass the duodenum may improve the durability of post-operative weight loss. GFI is a novel weight loss procedure that achieves this goal. I have demonstrated stable postoperative blood leptin levels in an obese rat model undergoing GFI. Future studies are needed to corroborate this observation.

#### Gastric Pouch Emptying Following Gastric Bypass Surgery
Sarah Stano et al, at the obesity nutrition research center, Columbia University, New York, have recently published an Excellent new study in SOARD journal. The authors evaluated the effect of meal size and texture on gastric pouch emptying as well as GLP-1 secretion following gastric bypass surgery.

32 gastric bypass patients were prospectively enrolled and randomized to either liquid or solid 600 kcal meal administered as one meal or three 200 kcal meals at 2-hour interval. 21 patients were re-tested one year after gastric bypass surgery. The authors conclude that gastric pouch emptying increases after gastric bypass surgery but it is not affected by meal texture. Meal texture, however, as well as meal size have a significant effect on peak GLP-1 and insulin secretion.

This is a very interesting study that reinforces the robust evidence we currently have about weight loss surgery mechanism of action. Both gastric sleeve and gastric bypass surgery increase gastric emptying and post-prandial GLP-1 secretion. Weight loss procedures like gastric balloon and endoscopic sleeve gastroplasty that delay gastric emptying do not alter GLP-1 changes and do not result in significant and durable weight loss.

Furthermore, the study demonstrates that liquid meals result in higher post-prandial GLP-1 level following gastric bypass surgery when compared to isocaloric solid meals. This finding is independent of gastric pouch emptying rate. GLP-1 is secreted by mucosal neuroendocrine cells called L cells. Liquid meals cover a larger number of L cells at higher rate and higher nutrient concentration than solid meals leading to higher GLP-1 secretion. Such discrepancy in GLP-1 secretion between liquid and solid meals is not found with regular gastric emptying. Dumping is prevented by several gastric emptying mechanisms that remain poorly understood. A form of dumping is, however, maintained via the Magenstrasse emptying pathway. Magenstrasse gastric emptying channels liquids from the gastric fundus into the antrum and through the pylorus directly into the duodenum. This pathway controls neuroendocrine cell stimulation and secretion of several hormones including GLP-1. Such control plays a central role in glucose homeostasis, insulin resistance, and energy metabolism. Loss of the Magenstrasse emptying pathway results in obesity and type diabetes. Bariatric surgery in the form of gastric bypass and gastric sleeve surgery restores gastric dumping. In the case of gastric bypass surgery, dumping is exaggerated and higher than normal GLP-1 secretion has consistently been demonstrated. In rare cases, patients develop postprandial hyperinsulinemic hypoglycemia after gastric bypass surgery. Such cases further illustrate the important role gastric emptying plays in glucose homeostasis.

#### Gastric Pouch Emptying of Solid Food in Gastric Bypass Patients
“Gastric pouch emptying of solid food in patients with successful and unsuccessful weight loss after Roux-en-Y gastric bypass surgery” by L.N. Deden et al is a recent publication in SOARD (Surgery for Obesity and Related Disorders). In this interesting article, the authors attempt to elucidate gastric bypass mechanism of action by studying gastric pouch solid food emptying. Altered gastro-intestinal motility is one of the most plausible mechanisms of action of weight loss surgery. Indeed, obesity and type 2 diabetes may be considered gastro-intestinal motility disorders resulting in abnormal post-prandial neuro-hormonal reaction to ingested food.

Several studies in the past have demonstrated that both gastric sleeve surgery and gastric bypass procedure increase gastric emptying and favor food dumping into the intestine stimulating the secretion of gut peptides like GLP-1 and PYY. In this article, the authors demonstrate the opposite; Increased gastric pouch emptying is associated with poor weight loss in a pilot study of 10 patients. The authors compared gastric pouch emptying in 5 gastric bypass patients with successful weight loss to a group of 5 gastric bypass patients with poor weight loss at least 2 years after surgery. they found that the faster emptying rate is mainly due to the first 15 minutes following food ingestion. The authors conclude that if their hypothesis is proven narrowing gastric pouch outlet may lead to decreased food emptying and as a result improved weight loss.

The idea of food retention in the stomach or gastric pouch leading to satiety and consequently weight loss is quite naïve. Gastric pouch outlet narrowing can only result in heartburn and esophageal dysmotility. We have had plenty of experience with this concept in Lap Band patients. We also know that endoscopic gastro-jejunostomy narrowing in the case of gastric bypass does not result in improved and durable weight loss. Accelerated food delivery into the intestines has been established in multiple studies evaluating gastric bypass and sleeve gastrectomy patients. Indeed, I have developed an effective surgery for gastroparesis based on these studies. I doubt that the results published by Deden et al will be reproducible by other investigators. Nonetheless, the authors raise an important question and studying gastro-intestinal motility in weight loss surgery patients will help elucidate some of the mechanisms of action underlying gastric bypass and sleeve gastrectomy.

#### Gastric Sleeve Migration in Weight loss Surgery
I read with great interest the article “Gastric Migration Crisis in Obesity Surgery” recently published in Obesity Surgery. The author, Dr. Runkel, is concerned about the increasing numbers of intra-thoracic migration of gastric sleeve leading to GERD and Barrett’s esophagus development. The mechanism behind sleeve migration into the chest remains unknown. The author points to the fact that sleeve lumen is almost as wide as the esophagus and with time and secondary to the pressure gradient between the abdomen and chest the sleeve migrates upwards. He adds that gastric pouch migration rate in gastric bypass cases is not known because most gastric bypass patients don’t develop GERD to be checked for post-op hiatal hernia development.

Dr. Runkel goes over the 2012 consensus recommendations of routinely dissecting the phreno-esophageal membrane during sleeve gastrectomy to look for a hiatal hernia. If present crural repair is recommended. He then quotes a number of studies that contradict this recommendation and show no benefit in concomitant hiatal hernia repair and sleeve gastrectomy in alleviating acid reflux or preventing de novo GERD.

The author adds there is no consensus on hiatal hernia repair technique. The crura are approximated over a calibrating tube of varying diameter. Suture placement anterior or posterior to the esophagus, mesh placement and cardia fixation vary among surgeons.

To understand sleeve migration, one need to understand hiatal hernia pathophysiology. Hiatal hernia develops and grows in response to chronic acid reflux. Acid reflux causes esophageal musculature to contract in a cephalad direction leading to progressive migration of intra-abdominal esophagus followed by cardia into the chest, thus forming a hernia. Hiatal hernia formation weakens the anti-reflux barrier and causes more reflux which in turns promotes hiatal hernia growth. This vicious circle leads to progression of disease and worsening symptoms with time. In the case of sleeve gastrectomy, both the small size of sleeve lumen and lack of attachment along the resected greater curvature lead to rapid hiatal hernia formation or growth in case of pre-existing small hiatal hernia, hence the term sleeve migration. Since most obese patients have a small hiatal hernia, it is not surprising to see a high number of sleeve migration. Post-gastric sleeve GERD occurs if the incisura angularis is narrowed, a mistake commonly committed in the early sleeve experience, or if a concomitant hiatal hernia repair is not performed. The gastric sleeve is a low compliance tube. When only a small portion of the sleeve lumen is subjected to negative intra-thoracic pressure, negative pressure is transmitted into sleeve lumen and probably across the pylorus leading to bile and acid reflux. Bile reflux is implicated in the development of Barrett’s esophagus. Indeed, a number of studies have shown increased Barrett’s esophagus incidence in gastric sleeve patients suffering from GERD.

Hiatal hernia repair is crucial in gastric sleeve surgery. Any size hernia must be repaired to avoid sleeve migration, GERD and Barrett’s esophagus leading to esophageal cancer. Sleeve migration does not happen in the absence of GERD and without the contraction of esophageal musculature.

#### Gastric Sleeve or Bypass after Nissen Fundoplication
Gastric Sleeve or Bypass after Nissen Fundoplication

Ronald in Houston sent us this question: “So which is better sleeve or bypass I have mesh in my stomach and have had Nissen fundoplication and several hernia repairs”.

Dear Ronald,

There is no one answer to your question. We tailor surgery to patient condition and choose the most effective and safest solution to help our bariatric patients. Both gastric sleeve and gastric bypass surgeries are effective weight loss solutions. They are equally safe and when done correctly, protect against acid reflux.

I recommend a good work-up prior to surgery by a competent acid reflux specialist and bariatric surgeon in Houston. Accordingly, a decision can be made on the most appropriate surgery for you. In certain cases, the fundoplication can be left intact and gastric bypass or sleeve gastrectomy performed below the wrap.

#### Gastric Sleeve Revision Surgery in Houston
Gastric Sleeve Revision Surgery Overview
Gastric sleeve surgery is currently the most commonly performed weight loss procedure in Houston, TX. When properly performed, Sleeve surgery results in significant and durable weight loss with minimal short-term and long-term complications. Proper sleeve surgery results in a banana shaped stomach with no twisting, narrowing or retained gastric fundus. The gastric fundus is the upper part of the stomach that stores ingested food, control gastric emptying, and secretes many hormones that affect appetite, hunger and energy metabolism. A retained gastric fundus following a poorly performed sleeve surgery results in poor weight loss and the development of GERD (gastroesophageal reflux disease). GERD also known as acid reflux results in heartburn, cough and food regurgitation. New onset GERD following sleeve surgery is a strong indication of a poorly performed gastric sleeve surgery.
When is Gastric Sleeve revision surgery performed?
If you had a gastric sleeve procedure and you are currently experiencing poor weight loss, or any GERD related symptom like chronic cough, heartburn, and food regurgitation please give us a call. Do not treat yourself with over the counter antacid medications. You need to be thoroughly evaluated by a heartburn and weight loss specialist. If you are found to have an incompletely resected gastric sleeve, or a narrowed sleeve lumen, revision surgery may be offered to amend the problem.
How does Gastric Sleeve revision surgery work?
A revision surgery is indicated following gastric sleeve to correct certain anatomic problems that are causing acid reflux related symptoms and poor weight loss. The most common gastric sleeve revision procedure performed at Houston Weight Loss Surgery Center and Houston Heartburn and reflux center is hiatal hernia repair and resection of retained gastric fundus. A hiatal hernia occurs when the upper part of the stomach migrates into the chest through an enlarged opening in the breathing muscle.  This results in significant weakness in the lower esophageal sphincter leading to bothersome acid reflux and bile gastritis following gastric sleeve surgery.
Is Gastric Sleeve revision a good option for me?
Revision surgery is a complicated procedure and many factors are taken into consideration when evaluating a bariatric patient for potential revision surgery. After thorough assessment, Dr. Darido will discuss with you and at length the best treatment options for you. When indicated, a revision sleeve procedure allows you to alleviate your acid reflux and put you back on the right path for weight loss and healthy life.
Who should perform your Sleeve revision surgery?
It is extremely important to choose a knowledgeable weight loss and heartburn doctor to perform your sleeve revision surgery. Why? Poor weight loss and acid reflux go hand in hand most often following incomplete gastric sleeve resection and poor hiatal hernia repair. A specialist in both fields of acid reflux disease and weight loss, like Dr. Darido, is the most qualified doctor to take good care of you.
How much does sleeve surgery cost?
Surgery cost varies depending on your insurance plan. Our insurance and finance specialists are available to answer all your financial questions.
What is my recovery time?
You will usually spend a night or two in the hospital after surgery. It takes around one week before you can go back to work.
Lets get started
If you would like to learn more about sleeve revision surgery, we encourage you to contact our office for a private consultation. During this relaxed and informative session, you will get to meet Dr. Darido and learn if you are a good candidate for revision surgery.

#### Gastric Sleeve Surgery after Heller Myotomy
Rebecca from Houston Sent us this question: “I’ve already has achalasia surgery 10 years ago where the stomach lining was wrapped around the esophagus can I still have a gastric bypass and if so, can it be done laparoscopically?”

Heller myotomy and partial fundoplication surgery is commonly performed for achalasia. During a Heller myotomy, your surgeon cuts open the muscle fibers of the lower esophageal sphincter to facilitate swallowing. The myotomy, (cutting muscle fiber) is typically extended into the proximal stomach where gastric pouch for gastric bypass surgery is constructed.

Your bariatric surgeon needs to first undo the partial fundoplication. Then, the bariatric surgeon constructs a gastric pouch away from the myotomy was performed to minimize staple line leak. Conversion of Heller myotomy to gastric bypass is typically done through tiny incisions or laparoscopically.

A second option is to convert a Heller myotomy and partial fundoplication to gastric sleeve surgery. This approach is feasible, but not recommended due to increased acid reflux after fundoplication take down.

A third option is to keep the fundoplication intact and construct a gastric pouch below the wrap. This approach is particularly used when dense adhesions are encountered between the wrap and posterior esophagus.

In summary, weight loss surgery is feasible after Heller myotomy. Extra care must be taken to prevent staple line leak. Overall, the surgery is safe and easily performed through tiny incisions.

#### Gastric Sleeve Surgery and GERD
I read with great interest the commentary on evaluating the feasibility of phrenoesophagopexy during hiatal hernia repair in sleeve gastrectomy patients. The commentary was recently published in SOARD by Dr. Jose Ferrer from the Bariatric and Metabolic Surgery Center in Valencia, Spain. The author reports his concern about the development of GERD, severe reflux esophagitis, and Barrett’s esophagus following gastric sleeve surgery. Ferrer recommends hiatal hernia repair during gastric sleeve surgery. However, herniorrhaphy alone is not enough sometimes. Additional techniques have been developed such as phrenoesophagopexy, Hill gastropexy, Teres ligament pexy, and different forms of fundoplications to augment the anti-reflux barrier.

Ferrer recommends leaving 2 cm of gastric tissue around the angle of His to preserve the phrenoesophageal angle. If a hernia is present, he recommends posterior hiatal repair and if the hernia is greater than 4 cm he favors gastric bypass surgery over sleeve gastrectomy.

I continue to be amazed by these studies and opinions regarding the effect of gastric sleeve surgery on GERD. As an acid reflux specialist and bariatric surgeon, I have found the gastric sleeve, when properly performed, to be a great anti-reflux procedure. Indeed, I offer hiatal hernia repair with sleeve gastrectomy to obese patients presenting for GERD management. I fully agree with Dr. Ferrer that a formal hiatal hernia repair must be performed concomitant with gastric sleeve surgery. Hiatal hernia repair technique varies greatly, however, among surgeons. Some bariatric surgeons perform an anterior repair which in my mind is completely useless. Other bariatric surgeons perform a posterior repair without esophageal mobilization which is equally useless. Based on these two commonly performed techniques, most sleeve gastrectomy patients are not receiving proper hiatal hernia repair. When the upper part of the gastric sleeve lumen is subjected to the negative intra-thoracic pressure, reflux (mainly bile reflux) is inevitable. The sleeve lumen is narrow and with low wall compliance. Consequently, it transmits the negative thoracic pressure effectively favoring not only acid reflux but also bile reflux from the duodenum across the pylorus. For this reason, hiatal hernia repair is of utmost importance in sleeve gastrectomy cases. Equally important is the sleeve resection. A narrowed or twisted sleeve lumen causes reflux. The most common mistake performed in gastric sleeve surgery is narrowing the natural angle of the stomach at the incisura angularis. The majority of bariatric surgeon place a bougie across the incisura angularis and start the resection hugging the bougie and obliterating the angle. Obliterating the incisura angularis creates a functional obstruction that favors acid reflux.

A properly performed hiatal hernia repair and a well contoured gastric sleeve are effective anti-reflux solutions. Persistent or new onset GERD following gastric sleeve surgery is not inherent to the nature of the procedure but rather a good indication of poor surgical technique.

#### Gastric Sleeve Surgery and Hiatal Hernia: Repair or Not?
Hiatal hernias and acid reflux are common occurrences in obese patients. There is an almost linear correlation between BMI and GERD. Indeed, elevated intraabdominal pressure in overweight patients stresses the delicate phreno-esophageal membrane. Weakness in this membrane leads to effacement of the angle of His, laxity in the diaphragmatic crura, and migration of the intraabdominal esophagus into the chest. With time, a hiatal hernia develops, and acid reflux worsens. Most obese patients presenting for gastric sleeve surgery suffer from GERD. The question that frequently arises: what to do with the hiatal hernia if present?

A recent prospectively randomized study by Klein et al, published in SOARD journal, showed no difference in GERD symptoms at one year after sleeve gastrectomy. Morbidly obese patients scheduled for gastric sleeve surgery and found to have a hiatal hernia less than 4 cm in axial displacement were randomly divided into two groups. The first group underwent gastric sleeve surgery with hiatal hernia repair and the second group received a sleeve gastrectomy without hiatal hernia repair. Both groups were closely followed, and statistical analysis showed no significant difference in terms of GERD related symptom resolution or de novo symptom formation between both groups. In other words, according to this group of bariatric surgeons in Houston, there is no need to repair a hiatal hernia measuring less than 4 cm in axial displacement during gastric sleeve surgery.

At Houston Weight Loss Surgery Center, we have learned over the past few years that any size hiatal hernia must be repaired during gastric sleeve surgery to prevent post-operative GERD and bile gastritis. The main purpose of hiatal hernia repair is to restore normal anatomy consisting of at least 3 cm of intra-abdominal esophagus. This allows the lower esophageal sphincter to be exposed to the positive intra-abdominal pressure; this is particularly important in the case of gastric sleeve surgery. An unrepaired hiatal hernia leaves the upper part of gastric sleeve lumen exposed to the negative intra-thoracic pressure. The narrow gastric sleeve lumen has low wall compliance that easily transmits the negative intra-thoracic pressure into the gastric lumen. This results in a pressure gradient across the diaphragmatic opening favoring not only gastro-esophageal reflux but also duodeno-gastric reflux.  Indeed, almost all sleeve gastrectomy patients with GERD and hiatal hernia have evidence of bile gastritis on upper endoscopy. Biliary acids also contribute to reflux esophagitis and Barrett’s esophagus development.

Gastric sleeve surgery and hiatal hernia repair go hand in hand to prevent de novo, persistent or worsening post-operative acid reflux. Meticulous surgical technique is key to achieve proper hiatal hernia repair and a well contoured gastric sleeve. When properly performed, bariatric patients experience a reflux free weight loss journey.

 

#### Gastric Sleeve Surgery and Type 2 Diabetes
Bariatric surgery, including gastric sleeve surgery, is the most effective treatment for type 2 diabetes. The combination of post-sleeve gastrectomy weight loss, decreased food intake and neuro-hormonal changes result in durable blood glucose improvement and in many cases Diabetes remission. Few studies, however, have addressed the preventative effect of gastric sleeve and bypass surgery on new onset type two diabetes development. “Preventative effect of bariatric surgery on type 2 diabetes in morbidly obese patients: a national French survey between 2008 and 2016 on 328,509 morbidly obese individuals” is a newly published study in the Surgery for Obesity and Related Diseases journal. This French nationwide retrospective study shows 82% reduction in new onset type 2 diabetes development following bariatric surgery in obese patients. Gastric sleeve surgery and gastric bypass were equally effective in reducing the development of type 2 diabetes.
Obesity is a major risk factor for type 2 diabetes. If you live in Houston and suffer from excess weight or type 2 diabetes, bariatric surgery may be a great solution for you. Don’t wait until you develop advanced type 2 diabetes to consider a safe, effective and minimally invasive procedure like gastric sleeve surgery. Gastric sleeve surgery unlike insulin supplementation reverses the underlying pathophysiology of type 2 diabetes. Gastric sleeve surgery increases gastric emptying. Gastric sleeve surgery promotes the secretion of neuroendocrine signals that favor lower insulin resistance, lower blood glucose levels and weight loss. Take control of your health today and invest in it, for your health is your best wealth. Early intervention in the form of sleeve gastrectomy is associated with a higher success rate of type 2 diabetes remission and lower rate of type 2 diabetes related complications.

#### Gastric Sleeve Surgery, De Novo Acid Reflux and Medical Tourism
Some patients from Houston elect to go to nearby Mexico for weight loss surgery for various reasons. Some have no medical insurance while others have very high deductibles. Affordable weight loss and cosmetic surgery packages are offered in several cities like Cancun and Tijuana. Patients can have a small vacation and come back to Houston with a gastric sleeve or tummy tuck.

Some are very lucky and receive quality surgery with fast recovery and no complications. Others, unfortunately, are hurt. Over the past one year, I have seen several gastric sleeve related complications particularly when performed in Mexico and mainly related to post operative acid reflux. Some have narrowing of the gastric lumen mainly at the level of the incisura angularis while others have a retained gastric fundus. A good number have a large hiatal hernia that is left unrepaired at the time of sleeve surgery. I am sure that many foreign bariatric surgeons are quite knowledgeable and skillful. Some, however, are unfortunately unqualified and Houstonians are falling victims.

Gastric sleeve surgery is one of the least challenging weight loss procedures to perform. Sometimes one may encounter a difficult case but overall the technique is simple and straightforward. The outcomes are easily reproduced when certain aspects of the surgery are taken into consideration. First, the gastric fundus must be completely mobilized and resected. Failure to do so results in poor weight loss and post-operative acid reflux. Second, the incisura angularis must not be narrowed. Failure to do so, results in vomiting, food regurgitation, severe acid reflux and possible staple line leak. Third, a large hiatal hernia must be repaired at the time of surgery. Obviously, a small indentation in the hiatus can be left alone. However, patients with a short intra-abdominal esophagus and GERD related symptoms upon presentation must be closely evaluated. A hiatal hernia in this setting ought to be fixed to prevent post-operative acid reflux. Finally, a corkscrew or twisted gastric sleeve can cause reflux. Every effort must be made to contour the staple line to prevent jagged edges that serve as reflux points.

The problem with de novo acid reflux following gastric sleeve surgery is not only limited to the immediate postoperative period. De novo reflux may surface years down the road. A study by Himpens et al. revealed a biphasic pattern in the symptoms of GERD during longer-term follow-up. In a subgroup of 30 patients followed-up for 6 years after LSG, GERD complaints were present in 23% of patients. Previously, this group of patients demonstrated a 22% GERD incidence at 1 year and then an incidence decrease to 3% at 3 years. The investigators commented that the development of a neofundus and a “relative mid-stomach stenosis” in gastric sleeve patients at long-term follow-up contributed to increased acid production and might explain the increased incidence of GERD. This is a fascinating theory that further supports our effort at keeping the incisura angularis as wide as possible while completely resecting the gastric fundus. Complete gastric fundus resection is key to gastric sleeve surgery. It allows for improved weight loss while preventing post-operative acid reflux. Neofundus formation may be inevitable with time but one thing for sure; complete gastric fundus resection will significantly limit the size and likelihood of neofundus development.

In a future blog I will discuss my take on gastric sleeve surgery as a mutilating procedure and what alternatives I came up with to replace the gastric sleeve.

#### Gastric Sleeve Volume: Does It Affect Weight Loss?
Two contradictory studies have recently been published about gastric sleeve volume and its effect on weight loss. Both studies used three dimensional gastric computed tomography with gas expansion to measure the gastric sleeve volume after surgery.

The first study, “Dilation of Sleeve Gastrectomy: Myth or Reality?” published in Obesity Surgery showed that more than 50% of patients will have gastric sleeve dilation at one year after surgery. Dilation mainly affected the gastric tube and was not associated with increased food intake or decreased weight loss during the 18-month follow-up after surgery. Interestingly, the authors show that the smaller the gastric sleeve lumen the higher the risk of dilation. Dilation is defined in this study as more than 25% increase in total gastric volume.

The second study, “Impact of Sleeve Gastrectomy Volumes on Weight Loss Results: a prospective study”, showed that weight loss at 18 months after sleeve gastrectomy was significantly higher in small volume gastric sleeve patients. Interestingly, the authors found no correlation between gastric tube volume and weight loss. In other words, gastric antrum volume determined the extent of postoperative weight loss; the smaller the antrum the higher the weight loss at 18 months after surgery.

Gastric sleeve surgery is a metabolic procedure that alters the interaction between ingested food and the gastrointestinal tract. Gastric emptying is increased and neuro-hormonal signals emanating from the stomach and intestines are altered favoring increased satiety and weight loss. Increased gastric emptying has been demonstrated in several studies. It is mainly due to gastric fundus resection and decreased gastric compliance as well as the elimination of the postprandial gastric accommodation reflex. The antrum is the gastric pump and it does promote gastric emptying especially when ingested food is rushed from the gastric fundus into the antrum. A retained gastric fundus after sleeve gastrectomy is associated with poor weight loss and postoperative acid reflux disease. A dilated gastric tube is different from a retained gastric fundus or poorly performed gastric sleeve. I agree with the authors of both studies that as long as the gastric fundus is properly resected weight loss is not affected by overall gastric sleeve lumen size. I am also of the opinion that a narrow gastric lumen does increase the risk of postoperative reflux. Gastric antrum volume however is unlikely to affect weight loss. The antrum is made of thick muscle wall and is less likely to dilate with time. Furthermore, the antrum promotes gastric emptying and therefore a preserved antrum is more likely to be associated with better weight loss. A radical antrectomy destroys the stomach function completely and reduces the gastric function to a mere tube for food passage. At Houston Weight Loss Surgery Center, we advocate the preservation of gastric antrum and complete resection of gastric fundus. Preserving the antrum prevents against narrowing of the incisura angularis. A narrowed incisura increases the risk of acid reflux, food regurgitation, staple line leak and probably decreased weight loss.

#### Gastric Sleeve: Where You Go First Matters
Gastric sleeve surgery consists of cutting out the lateral part of the stomach. The result is a sleeve like or banana shaped stomach. A smaller stomach capacity creates mechanical restriction to limit meal size. At first glance, one may assume that the smaller the meal size the better the weight loss. Gastric sleeve surgery, however, is not simply a restrictive procedure like Lap Band. Gastric sleeve surgery is a metabolic procedure that alters several hormones secreted by the stomach and intestines that affect your appetite, satiety, metabolism and ultimately weight loss. Aggressive gastric sleeve resection destroys stomach function and rather than promoting weight loss it results in acid reflux development.

Consequently, Bariatric surgeons at Houston Weight Loss Surgery Center, pay special attention to gastric sleeve surgical technique to maximize weight loss while minimizing side effects. Gastric sleeve is gently contoured to result in a straight sleeve lumen with no twisting or narrowing. A concomitant hiatal hernia is repaired to avoid the development of acid reflux after sleeve gastrectomy.

By paying attention to surgical technique, our bariatric patients have been able to achieve maximal weight loss results with no heartburn and no food regurgitation. Recovery from surgery has been smooth and uneventful.

To summarize, not all sleeves are created equal. Weight loss outcome and post-operative quality of life greatly depends on surgical technique. Understanding gastric sleeve surgery mechanism of action and appreciating its metabolic effects are crucial to successful outcomes.

#### Gastroparesis after Nissen Fundoplication
Jose from San Antonio sent us this question: “After a stomach emptying process at the beginning of 2020, the diagnosis was gastroparesis. I had a prior fundoplication in 2005. I was prescribed medication for the gastroparesis, to which I had allergic reactions to the Metoclopramide 10mg. I am still using the Ondansetron ODT 4mg for acute nausea, which helps but do not take away the nausea. I have found that ginger brings quick relieve, but it doesn't last long. Over the last 3 months I have lost 30 lbs due to being nauseated consistently throughout the day, and would wake up at night, dry heaving. I eat several small meals throughout the day, and there are times that I eat nothing at all, as I would gag as I bring the food to my mouth. I am full after a few bites and stay full for long after. I also dry heave during the day. I am seeing my Endocrinologist monthly for type 2 Diabetes, Cholesterol, Hypothyroidism and Hypertension. Currently I am taking Synjardy XR 12.5mg-1000mg, 2 a day, Glimepiride 2g, 1 a day, and Ozempic 1mg per dose, 1 a week. I still have stomach emptying during the night, which makes my sugar spike when I least expect it. My endocrinologist suggests gastric pacemaker, but I declined based on what I read on your blog. My quality of life has gone down. Can I have the surgery to improve my health and just maybe reverse my Diabetes/High Cholesterol/Hypothyroidism. I also have osteoarthritis and will be having knee-replacement in December.”

Dear Jose,

Gastroparesis or delayed gastric emptying may develop in the setting of diabetes. Diabetic gastroparesis contributes to erratic blood sugar control in addition to debilitating symptoms like nausea, vomiting and abdominal pain. Medications like Metoclopramide, commonly known as Reglan, are used to promote gastric emptying. However, efficacy of Reglan is limited, and long-term use is associated with serious side effects. Gastric pacemakers are quite ineffective, and I do not recommend pacemaker placement for gastroparesis treatment.

An antrum preserving longitudinal gastrectomy along the greater curvature of the stomach is a promising procedure for treatment of gastroparesis. This approach was developed based on data from sleeve gastrectomy that show increased gastric emptying following gastric sleeve surgery for morbid obesity. I have personally tried the procedure in around 20 patients. All patients had immediate and complete gastroparesis related symptom resolution. Most importantly, longitudinal gastrectomy can be performed between the gastric antrum and fundoplication. Therefore, the fundoplication is preserved sparing you a potentially complicated revision surgery.

Other surgical option for gastroparesis treatment are available including pyloroplasty and gastric bypass surgery. However, in our own experience at Houston Weight Loss Surgery Center, we have found that a limited longitudinal gastrectomy to be the most effective and most reliable treatment for gastroparesis.

#### Get Involved With Your Food
There is no better alternative to home cooking when it comes to a healthy lifestyle.  “Cooking is probably the most important thing you can do to improve your diet. What matters most is not any particular nutrient, or even any particular food: it’s the act of cooking itself. People who cook eat a healthier diet without giving it a thought. It’s the collapse of home cooking that led directly to the obesity epidemic,” said Michael Pollan in his book: Cooked: A Natural History of Transformation. At Houston Weight Loss Surgery Center, the first question I ask my patients is: Do you cook at home? The answer is negative 99% of the time. Most bariatric patients don’t cook at home because, like most Houstonians, they don’t have time. “We do find time for activities we value, like surfing the Internet or exercising,” says Pollan. “The problem is we’re not valuing cooking enough.” We are not getting involved in our food. We are not asking the questions. What’s in this dish? Where do the ingredients come from? What kind of spices are theses or is it simply artificial flavoring and food additives? Are there any antioxidants in what I am eating or am I ingesting empty calories? Is there any fiber in my food? … “Cooking links us to nature; it links us to our bodies. It’s too important to our well being … you’re going to use higher-quality ingredients than whoever is making your home-meal replacement would ever use. You’re not going to use additives. So the quality of the food will automatically be better.”
Let the whole family be involved in meal preparation. Visit your local farmers market for fresh ingredients. Learn how to cook and perfect your favorite dishes. Ask a friend, a relative, or a coworker for a certain recipe to learn. Check the Internet for an endless number of meal preparation instructions and browse YouTube for hundreds of cooking videos. (I like Jamie Oliver website www.jamieoliver.com)
The obesity epidemic in this country has its roots in our kitchens. Microwaves have replaced stovetops. Frozen foods have trumped local fresh vegetables and fruits. Junk food has destroyed our taste buds and laid waste to our waists. Take over your nutrition today before it is too late. Obesity and Diabetes are still on the rise and unless we target the root of the problem our health is in serious jeopardy. You can fix the problem; Get involved with your food and take action!

#### Going from Sleeve to Bypass: How Much Weight Do You Lose?
Gastric sleeve to bypass conversion usually does not lead to substantial additional weight loss if the original gastric sleeve surgery was done properly. Both sleeve gastrectomy and gastric bypass are metabolic surgeries with similar mechanisms of action. They mainly alter gut hormone secretion in response to food intake by increasing gastric emptying and food passage through small intestines.  Gut hormones like GLP-1 (better known under its pharmaceutical name of Ozempic, Mounjaro, Zepbound…) are secreted by the intestines in response to food intake. These hormones increase satiety, decrease appetite and cravings, as well as improve blood sugar level, leading to weight loss. Major studies such as SLEEVEPASS, SM_BOSS and STAMPEDE trials have shown comparable weight loss and health improvement between gastric sleeve and gastric bypass surgery.

Therefore, if the original gastric sleeve was performed correctly, converting to gastric bypass changes the anatomy but does not significantly enhance the metabolic weight loss effect. 

For this reason, when weight loss stalls or weight is regained after an initial properly performed gastric sleeve surgery, conversion to gastric bypass may not be the best option for you to lose weight. An experienced bariatric surgeon may offer you one of two options in this case:

 	Pharmacotherapy with GLP-1/GIP agonist medications (like Ozempic and Zepbound) along with behavioral changes is a great first line treatment. These medications are effective and safe with limited side effects.
 	If GLP-1 therapy is not enough, Single Anastomosis Duodeno-Ileal Bypass (SADI) is increasingly considered the procedure of choice in many cases after failed gastric sleeve surgery. SADI is a malabsorptive procedure that consists of bypassing a long segment of the small bowel to limit the absorption of calories and nutrients. The risk of diarrhea, vitamin deficiency and malnutrition is around 10%. Nutritional supplementation and adequate protein intake are needed. SADI is a newer bariatric operation and long-term outcome data are still not available.

If the initial gastric sleeve surgery was not properly performed resulting in poor weight loss or severe acid reflux, then three options are available depending on gastric sleeve anatomy:

 	For a retained gastric fundus (upper part of the sleeve was not completely resected), a re-sleeve is indicated
 	For a neo-fundus formation (dilated upper part of sleeve) resulting in acid reflux but adequate weight loss, hiatal hernia repair is all what you need to stop reflux. This condition typically occurs secondary to functional obstruction at the stomach angulation due to improper staple line alignment during surgery. https://houstonsleevesurgeon.com/the-perfect-sleeve-gastrectomy-to-prevent-gerd
 	For a narrowed sleeve lumen (Stomach was aggressively resected over a small calibration tube) resulting in severe acid reflux, conversion to gastric bypass is indicated to bypass the narrowing.

For additional information and in-depth evaluation for weight regain or limited weight loss following gastric sleeve surgery, give us a call at 832-963-1803. At Houston Weight Loss Surgery Center, we offer individualized, safe and reliable weight loss solutions that best fit your condition.

References:

 	Salminen P, Helmiö M, Ovaska J, et al. Effect of laparoscopic sleeve gastrectomy vs laparoscopic Roux-en-Y gastric bypass on weight loss at 5 years among patients with morbid obesity: the SLEEVEPASS randomized clinical trial. JAMA 2018;319:241-54. 10.1001/jama.2017.20313
 	Peterli R, Wolnerhanssen BK, Peters T, et al. Effect of laparoscopic sleeve gastrectomy vs laparoscopic Roux-en-Y gastric bypass on weight loss in patients with morbid obesity: the SM-BOSS randomized clinical trial. JAMA 2018;319:255-65. 10.1001/jama.2017.20897
 	Schauer PR, Bhatt DL, Kirwan JP, et al. Bariatric surgery versus intensive medical therapy for diabetes — 5-year outcomes. N Engl J Med 2017;376:641-51. 10.1056/NEJMoa1600869

#### Heart Health for 2017
Dominik D. Alexander, PhD, MSPH and colleagues have recently published a meta-Analysis of randomized controlled trials and prospective cohort studies of Eicosapentaenoic and Docosahexaenoic long-chain Omega-3 fatty acid consumption and coronary heart disease risk. This well-designed study was published in the first issue of the Mayo Clinic Proceedings journal for 2017. The authors analyzed 18 randomized controlled studies and 16 prospective cohort studies conducted between 1947 and 2015. They concluded that omega 3 fatty acids supplementation is not associated with a statistically significant heart health improvement. However, in high risk population, namely patients with elevated low density lipoprotein cholesterol and triglycerides, omega 3 fatty acids resulted in significant reduction in heart related disease events.
Obesity and type 2 diabetes are major risk factors for Heart disease in the United States. Poor diet and sedentary lifestyle are fueling the twin obesity-diabetes epidemic. Our modern processed diet is poor in omega 3 fatty acid and rich in omega 6 fatty acids. High insulin levels secondary to high sugar and refined carbohydrate consumption in the setting of low omega 3 fatty acids increase the conversion of omega 6 fatty acids to arachidonic acid. Arachidonic acid is a central player in cellular inflammation. Chronic inflammation is associated with aging, cardio-vascular disease, cancer development, dementia … The addition of omega 3 fatty acids to our diet as well as the regular consumption of seafood while avoiding processed and refined carbohydrates especially in the obese population is highly recommended.

If you are overweight, suffer from high cholesterol or triglyceride levels, and if you have diabetes or pre-diabetes, let the addition of omega 3 fatty acids to your diet be your new year resolution. Small dietary changes in your everyday life can have great effect on your longevity and health. Your best wealth is your health. Start investing in your health today. For more questions and if you desire additional dietary recommendations, please do hesitate to contact our nutritionist at Houston Weight Loss Surgery Center.

#### Heartburn after Gastric Sleeve Surgery in Dallas
James sent us this question: “Hi!  I live in Dallas and had a gastric sleeve 3 years ago.  I have severe reflux and had a scope done last week showing an esophageal ulcer and recurrent hiatal hernia.  My biopsies are pending.  I had a preop scope showing a hiatal hernia which was fixed during my sleeve.  How can I know if the incisura angularis was narrowed during my surgery? Is this something that can be seen during my scope?  I really do not want to have another surgery, but I don’t want to get esophageal cancer.”

Dear James,

The three components of successful sleeve gastrectomy include:

 	Proper hiatal hernia repair
 	Complete gastric fundus mobilization and resection
 	Wide incisura angularis and preserved gastric antrum

Proper hiatal hernia repair requires distal esophageal mobilization. Most bariatric surgeons are not trained to repair properly repair hiatal hernias. The result of poorly repaired hiatal hernia is early recurrence. Recurrent hiatal hernia in the setting of sleeve gastrectomy results in severe acid reflux independent of a narrowed incisura angularis.

A narrowed incisura angularis is best diagnosed by an expert bariatric surgeon using both upper endoscopy and UGI contrast study. A gastroenterologist performing endoscopy after sleeve gastrectomy is not likely to appreciate narrowing of incisura angularis. Indeed, incisura angularis narrowing is functional rather than mechanical. It is suspected when the angle between the horizontal and vertical part of the stomach is quite sharp and requires some maneuvering to navigate during endoscopy.

We have noticed that over time, the incisura angularis dilates and repair of hiatal hernia is enough to control acid reflux in the setting of sleeve gastrectomy. Of course, severe narrowing requires sleeve to bypass conversion to remedy the acid reflux problem.

#### Heartburn After Sleeve Gastrectomy
If you live in Houston, and you are considering sleeve gastrectomy for weight loss, read this first.

A properly performed sleeve gastrectomy does not result in acid reflux. Indeed, a properly performed sleeve gastrectomy along with hiatal hernia repair results in acid reflux resolution. Surgical technique and understanding of sleeve gastrectomy mechanism of action as well as GERD pathophysiology are keys to achieve successful outcome. Aggressive stomach resection over tight caliber bougie does not result in better weight loss. Rather it mutilates stomach function leading to severe acid reflux after sleeve gastrectomy. Therefore, we advocate preserving most of the gastric antrum, avoid narrowing sleeve lumen, and completely resecting gastric fundus along with hiatal hernia repair to maximize weight loss and minimize heartburn development.

If you have undergone sleeve gastrectomy and currently suffer from heartburn, you have several options to treat your acid reflux problem. First, if a hiatal hernia is present, it must be repaired. If sleeve lumen is not arrowed and gastric fundus is not redundant, your chances at acid reflux control and heartburn elimination are quite high. If sleeve lumen is narrowed, hiatal hernia repair by itself is not enough and sleeve gastrectomy to gastric bypass conversion is recommended to control heartburn.

Patients who develop acid reflux several years after sleeve gastrectomy have a slightly different pathophysiology. At the time of sleeve gastrectomy, these patients most likely did not have a hiatal hernia. They underwent a sleeve gastrectomy with functional obstruction at the incisura angularis. Over time, functional obstruction leads to acid reflux which in terms results in hiatal hernia development also called gastric sleeve migration into chest. Hiatal hernia development worsens acid reflux which in turn causes the hiatal hernia to grow. Patients are typically started on PPIs but symptoms are partially controlled. By the time patients present to Houston Weight Loss Surgery Center, they have already reached stage 3 or 4 GERD. Most patients at this stage have a widened incisura angularis and conversion to gastric bypass is unnecessary to control acid reflux. Hiatal hernia repair by itself is sufficient to control heartburn unless there is significant esophageal dysmotility.

#### Heartburn After VSG
Yolanda from Houston sent us this question:
“Hello, in June 2014 I had VSG surgery and hiatal hernia repair. I lost 135 pounds, and my acid reflux was better for a while but slowly came back over the years. I regained all the weight and became sick with acid reflux. In June of this year, I had gastric bypass and hiatal hernia repair to fix the reflux. My Demeester score before surgery was around 35. Since surgery in June, I have lost 80 pounds, but my reflux has become so much worse. I can’t sleep because my stomach and esophagus stay on fire. It doesn’t matter if I eat or don’t eat, it’s the same. I had an endoscopy in August where my surgeon just wrote he believes I am sabotaging myself with food and doesn’t see anything on the endoscopy which is totally untrue. It’s 6am and I haven’t had food since yesterday evening (a protein bar) and I am on fire. I then had a barium swallow which showed a small hiatal hernia which was supposed to have been repaired. The barium swallow showed mild reflux, but the radiologist only had me drink a very small portion since I’d had bypass. Most recently I had manometry with pH impedance which came back with a Demeester score of 56, mostly non-acidic contents. My surgeon still dismisses me. He sent me home with baclofen and told me to come back in a month. It seems to help some, but it makes me sleep all day which is impossible for me to function like that. I’m also on 40mg omeprazole which does nothing and Carafate 4 times a day which helps some but not much. I am refluxing into my throat during the night which is very scary. I really need help because I don’t know where to go from here and I am miserable. Thanks”.
Dear Yolanda,

The most common cause for acid reflux after VSG is narrowing of incisura angularis during stomach resection. The incisura angularis in the junction of the vertical and horizontal parts of the stomach. It can be easily narrowed especially if the bariatric surgeon is using a small size calibration tube. Conversion of VSG to gastric bypass is usually a good solution to bypass the functional obstruction and aloe free flow of gastric content away from esophagus into intestines. If the hiatal hernia is not properly repaired during this procedure and the gastric pouch is left too long/large, reflux may persist. In addition, if the alimentary limb of the gastric bypass is too short, bile reflux may also occur. This condition is less likely, however, to occur as most bariatric surgeon choose a 70 to 100 cm alimentary limb length. You mention you had esophageal manometry. I am interested in knowing the lower esophagus sphincter, LES, pressure. If LES pressure is low, reflux is more likely to occur. You also have a very high Demeester score after gastric bypass. The Demeester score reflects how acidic the esophagus is. Typically, with gastric bypass there is decreased stomach acid content because most of the stomach is bypassed. Non-acidic reflux is more likely to be present as you have mentioned. In this case, I am suspecting food stasis in the gastric pouch or esophagus. Food stasis is associated with food fermentation which decreases pH values and lead to falsely elevated Demeester score. Food stasis occurs in cases of ineffective esophageal motility or narrowing of gastric pouch outlet.

Baclofen, a GABA receptor agonist, reduces transient lower esophagus sphincter relaxation and increase LES basal pressure but is associated with drowsiness and dizziness, thus limiting its efficacy. Omeprazole helps reduce stomach acid secretion, but it has no effect on non-acid reflux. Carafate covers the esophagus lining and helps alleviates heartburn, but it does not stop reflux.

Hiatal hernia repair to move the gastric pouch and LES from the negative pressure of the chest is indicated in your case. If the gastric pouch is large, size reduction is needed to reduce acid secretion. Additional procedures may be needed depending on your workup findings.

Please refer to our previous blog on the same subject: https://houstonsleevesurgeon.com/persistent-heartburn-following-sleeve-to-bypass-conversion.

Key Points

 	Acid reflux after VSG is mostly caused by narrowing at the incisura angularis.
 	Conversion from VSG to gastric bypass usually improves reflux by relieving functional obstruction.
 	Persistent reflux after conversion may be due to an unrepaired hiatal hernia, an oversized gastric pouch, or a short alimentary limb.
 	Low LES pressure, ineffective esophageal motility, or a narrowed pouch outlet can contribute to acid reflux.
 	Medications such as baclofen, omeprazole, and Carafate may relieve symptoms but do not correct mechanical causes of reflux.
 	Hiatal hernia repair and, if needed, pouch size reduction are key steps in treating persistent reflux after conversion.
 	Additional interventions may be required depending on diagnostic findings.

#### Heartburn and Acid Reflux with Weight Regain after VSG
A 59-year-old female presented to my office with severe acid reflux related symptoms including heartburn, cough, and food regurgitation not responsive to Omeprazole, a proton pump inhibitor.  She had a sleeve gastrectomy 11 years ago and she initially lost 100 pounds. Her current BMI is 35. Unfortunately, she has gained back around 75 pounds over the past two years. A year ago, she started experiencing GERD related symptoms. Of note the patient did not have acid reflux before or shortly after gastric sleeve surgery. She did however have a hiatal hernia that was concomitantly repaired during her initial weight loss procedure according to her operative report.
Her acid reflux workup included upper endoscopy, esophageal manometry and UGI contrast study. Endoscopy showed a recurrent hiatal hernia with minimal axial displacement but severe angulation in the upper 2 inches of the sleeve against the breathing muscle. The angulation created the appearance of a dilated proximal sleeve pouch or what we call as neo-fundus formation. Physiologically, this anatomic configuration traps stomach acid near gastro-esophageal junction. An acid pocket in this area greatly exacerbates acid reflux. Manometry showed a hypercontractile esophagus and slightly increased lower esophagus basal pressure. These manometric findings are secondary to severe acid reflux and scar tissue formation around the lower esophageal sphincter. Of note, the rest of the gastric sleeve lumen appeared normal with no twisting or narrowing at the lower one third of the stomach (incisura angularis).
I offered the patient hiatal hernia repair to stop acid reflux. I also recommended conversion of gastric sleeve to single anastomosis duodenal -ileal bypass to promote weight loss. Patient agreed to proceed with anti-reflux surgery, but she decided to postpone weight loss surgery revision.
Laparoscopic exploration was carried, and severe adhesions were encountered. As predicted the upper part of gastric sleeve was sharply angulated and with meticulous dissection the stomach was released from surrounding scar tissue. The hiatal hernia was reduced, and 3 to 4 centimeters of intra-abdominal esophagus were obtained to re-create the anti-reflux barrier. Patient tolerated the procedure with no complications. Her acid reflux symptoms completely resolved following surgery.
If you struggle with acid reflux following sleeve gastrectomy, contact the acid reflux experts of Houston Heartburn and Reflux Center. We offer a comprehensive workup and effective treatment tailored to your condition.

#### Heartburn Treatment Following Sleeve Gastrectomy
Andrea from Houston sent us this question: “I had a gastric sleeve surgery roughly 8 years ago.  My heartburn is getting worse and worse. I require several tums to make it through the night. Heartburn is worse at night when lying down. I also have cough and taste acid in my mouth. I would like to convert the sleeve to possible bypass. Thank you”.
Dear Andrea,
Heartburn treatment after sleeve gastrectomy is not always a sleeve to gastric bypass conversion. Gastric sleeve to bypass conversion is only needed in cases of sleeve lumen narrowing. A poorly performed gastric sleeve may be associated with twisting or narrowing of lumen leading to backflow of bile and acid into esophagus. Nowadays, we rarely encounter this complication. The most common cause of heartburn following sleeve gastrectomy is the presence of a hiatal hernia.
A hiatal hernia is an enlarged opening in the diaphragm or breathing muscle through which gastric sleeve herniates into chest. A hiatal hernia weakens the anti-reflux barrier resulting in acid reflux. Hiatal hernia repair restores the anti-reflux barrier, and it is associated with more than 95% success rate. The procedure is outpatient. Surgery is performed through tiny incisions, and it is associated with minimal pain and fast recovery.
If you suffer from heartburn after sleeve gastrectomy do not hesitate to contact us. Gastric sleeve to bypass conversion is not needed all the time.
Other symptoms of acid reflux following sleeve gastrectomy include food regurgitation, cough, and sore throat especially at night when laying down as you mentioned in your question. Furthermore, Bile reflux, in addition to acid reflux, is quite common following sleeve gastrectomy. For this reason, proton pump inhibitors and other acid suppressors have limited efficacy in controlling GERD symptoms following gastric sleeve surgery.

#### Hiatal Hernia Repair During Sleeve Gastrectomy Is Safe and Feasible
“Concomitant hiatal hernia repair with laparoscopic sleeve gastrectomy is safe: analysis of the ACS-NSQIP database” by Safadi et al is a retrospective review 32581 patients who underwent sleeve gastrectomy between 2010 and 2014. This database is part of NSQIP, the American College of Surgeons National Surgical Quality Improvement Program. 14.4% of those patients underwent a concomitant hiatal hernia repair. There was no difference in the 30-day mortality and morbidity rates between those who underwent a gastric sleeve procedure with hiatal hernia repair and those who only had a sleeve gastrectomy. 

Hiatal hernia repair, when performed by expert acid reflux and weight loss surgeons is safe. It may be more technically challenging in the morbidly obese patient especially in the presence of an enlarged liver due to steatohepatitis. Bariatric surgeons, however, continue to debate the need to repair hiatal hernias during gastric sleeve surgery. Should all hiatal hernias be addressed irrespective of size? Does sleeve gastrectomy improve, worsens or causes GERD postoperatively irrespective of hiatal hernia repair? 

It is our experience at Houston Weight Loss Surgery Center, that a well performed gastric sleeve procedure is associated with improvement of existing GERD. The components of a well performed sleeve gastrectomy are:
1-	Any size hiatal hernia must be repaired
2-	Gastric fundus must be completely resected
3-	Incisura angularis must not be narrowed
4-	Sleeve lumen must be straight and free of any kinking or narrowing

Indeed, sleeve gastrectomy that follows these guidelines is as good as Nissen fundoplication in curing and preventing GERD. The most commonly accepted explanation for GERD is related to increased transient lower esophageal sphincter relaxation, TLESR, events. Gastric fundus greatly affects the frequency of TLESR events. Resecting the gastric fundus and wrapping it around the distal esophagus may have the same effect on reducing TLESR and improving GERD.

Additional studies are needed to prove the long-term effect of sleeve gastrectomy on GERD. However, it remains a fact that preventing both mechanical and functional gastric sleeve lumen narrowing while completely resecting the gastric fundus are crucial steps in alleviating GERD related symptoms. Concomitant repair of a hiatal hernia furthers reinforces the anti-reflux barrier. It prevents the herniation of the gastric sleeve into the chest which exposes the intra-gastric and non-compliant lumen to negative intrathoracic pressure. This in turns transforms the sleeve lumen into a suction pump causing bile and acid reflux into the esophagus. From this perspective, we advocate the safe and concomitant hiatal hernia repair with sleeve gastrectomy.

#### Hispanics Undergoing Bariatric Surgery: A New Study
The study is titled: ”Excess weight loss and cardio-metabolic parameter reduction diminished among Hispanics undergoing bariatric surgery: Outcomes in more than 2000 consecutive Hispanic patients at a single institution”. It was published in the journal of The American College of Surgeons, JACS, in this month issue.

2002 Hispanic patients underwent bariatric surgery from 2008 till 2014 including 1235 gastric bypass, 600 gastric sleeve and 167 gastric band surgeries. This is the largest series published so far for Hispanic patients undergoing weight loss surgery. Hispanic adults are twice more likely to have diabetes and suffer more serious complications than non-Hispanic whites. Hispanics have a higher incidence of end stage renal disease when compared to Caucasians and have demonstrated a higher increase in the metabolic syndrome over the past 30 years when compared to non-Hispanic whites. It is obvious that the burden of obesity is significant in the Hispanic community and this study is quite relevant to our Houston patient population.

Bariatric surgery is the most effective and reliable treatment for morbid obesity and diabetes as well as other obesity related comorbidities. We now have 11 randomized controlled trials demonstrating the superiority of surgical over medical treatment for diabetes. However, the efficacy of bariatric surgery in minority groups in the United States has not been well defined. This report offers a comprehensive evaluation of bariatric surgery outcome in Hispanic patients. It demonstrates that gastric bypass and sleeve surgeries are effective weight loss modalities. There was a significant decrease in insulin, oral hypoglycemic, and hyperlipidemia medications after gastric bypass and gastric sleeve surgery. Interestingly, acid reflux medication reduction or elimination was higher for gastric sleeve patients (40%) compared to 34% for gastric bypass patients. However, these numbers are much lower than the reported rates of 74% in non-Hispanic cohorts. Similarly, excess weight loss was significantly lower in this study group when compared to non-Hispanic white and African American cohorts studied at other large volume bariatric centers.

The retrospective nature of this study has several limitations but does raise some interesting questions. Further prospective and randomized studies are needed to answer these questions. Why are patients of Hispanic origin less successful with gastric sleeve and bypass surgery than other ethnic groups? Is it related to certain genetic differences or lifestyle disparities? Why do patients of Hispanic origin continue with acid reflux medications especially after gastric bypass surgery? Are these medications prescribed to them or bought over the counter? Do they really have acid reflux disease or just treating dyspepsia related symptoms? We hope that additional studies will help answer these questions in the near future.

#### Holiday Eating Tips From Houston Weight Loss Surgery Center
Merry Christmas From Houston Weight Loss Surgery Center!
The holidays are a big challenge for eaters. Over-indulging in rich food, decadent deserts and large quantities of alcohol is very common around this time. What can you do if you are trying to maintain your weight?
First, enjoy your time. The holidays are meant to be a happy time and eating is one the great pleasures in life. We shouldn’t stress about food too much. “Eat what you want on the holidays but eat it more slowly and drink it more slowly than what you ordinarily would”, said Michael Pollan. Enjoy the food you are consuming with friends and family. After all it is not about quantities and excess calories but rather few savory bites you share with others.
The bariatric experts at Houston Weight Loss Surgery Center invite to be conscious and aware of what and how much you eat this holiday season. Count your calories and increase your activity. Take a walk after your meals or do some Yoga in the morning and you will feel much better. Remember the poor and those who are hungry this season. Give some of your food to needy people in your local community. You will feel lighter, happier and less stressed. Give thanks and you will be more satisfied than stuffing yourself with large quantities of food. Practice mindful eating and have a wonderful holiday season and happy new year!!

#### Holiday Meals Still Matter
“The Meals That Still Matter” is a well written article I have recently enjoyed reading in the Wall Street Journal. Bee Wilson, a British food writer and journalist, is the author. She reports that “Holidays are now the only time of the year when we really focus on what and how we eat”. Wilson further adds: “In our daily meals, we have become starved for ritual, which can make it feel as if life has lost its rhythms… In years gone by, the holiday meals of winter were just one feast among many. The whole year was punctuated with moments of wetness and celebration. There were harvest feasts and midsummer feasts, pig-killing feasts and saint’s days”. She then talks about Christmas, Diwali and Passover feasts and shows how food items and certain dishes were woven into the fabric of society in the Catholic world. Wilson explains that we deprive ourselves of half the value of food when eat alone. Indeed, a study showed that fewer than one third of families in Britain manage to eat dinner together on most weekdays. The article ends with a melancholic note: “For a few days, we gather and treat food like it actually matters. And then we go back to normal life, where the question of what to cook for dinner falls lower on our list of priorities than what case to buy for our new iPhone”.

At Houston Weight Loss Surgery Center, our most important message to our patients desiring to lose weight is to treat food like it really matters. If you do not invest in your food and give it a priority in your life you cannot lose weight. You are what you eat and what you eat has a huge impact on your health and well being. Our most successful weight loss surgery patients understand this concept and apply it on a daily basis. Sleeve and gastric bypass surgery patients who take food seriously manage to maintain weight loss for years to come. On the other hand, bariatric patients who don’t have time for grocery shopping, home cooking and meal prepping fail to maintain durable weight loss. Our hectic modern lifestyle has hijacked our eating rituals and replaced them with fast food on the go and frozen meals in the microwave. Consuming a home cooked meal with family and friends rejuvenates our bodies. Let food be thy medicine. For this holiday season, invest in your food for your health is your best wealth.

#### Holiday Weight Gain: Now What?
Holiday Weight Gain: Now What?

Most of us gain 1 to 2 pounds over the holiday period between Thanksgiving and New Year’s Day. Office parties, family dinners, out of town relative receptions, and friend gatherings revolve around large amount of rich food consumption. In the setting of a sedentary lifestyle, high calorie food items including alcohol, overwhelm the neuro-hormonal system that tightly regulates body weight. Individuals with decreased metabolism are particularly vulnerable. They tend to gain more weight and have difficulty dissipating the gained weight shortly after the holidays are over.

Avoiding weight gain around the holidays is difficult. It requires will power, awareness, knowledge and mindful eating. We ask our patients to be aware of how many calories they are consuming daily and make appropriate adjustment. Increase exercise and weigh yourself regularly. If you notice your weight has increased counteract by reducing your calorie intake and increasing your activity. One technique that I find successful in holiday parties is to eat slowly, while savoring 3 to 4 bites of each food item. Always be mindful and stop eating when full. You don’t have to eat just because food is present in front of you.

It is hard to separate celebrating with family and friends from overeating and overindulging. These holiday rituals are entrenched in our psyche and culture. If you have gained weight over the past few weeks, here are some useful tips to start the new year:

 	Drink plenty of water throughout the day
 	Stop soda and all other sugary drinks
 	Avoid sweets of all kind and take control of your sugar cravings
 	Increase fiber in your diet by consuming more fruits and vegetables
 	Stop all processed food
 	Increase your calorie intake in the morning and reduce it in the evening
 	Increase good fat sources like olive oil, avocados and reduced fried food

From Houston Weight Loss Surgery Center, we wish a happy new year full of health and happiness.

#### Houston Bariatric Surgery
Are you contemplating bariatric surgery for 2020? If you live in Houston and have been struggling with excess weight for a number of years, we may be able to help you. Houston weight loss surgery center offers one of the safest, and most effective weight loss solutions in the greater Houston area.

Gastric sleeve surgery remains our most commonly performed weight loss procedure. Combined with proper hiatal hernia repair, gastric sleeve surgery offers excellent weight loss results along with resolution of heartburn and acid reflux. Gastric sleeve surgery is an overnight minimally invasive procedure. Recovery is fast and complications rate is very low.

If you suffer from Diabetes, high blood pressure, sleep apnea, and fatty liver disease bariatric surgery may be your best treatment option. If weight loss is one of your 2020 new year resolutions give us a call at 281-205-3205.

#### Houston Weight Loss Surgery Center Recommends Dark Chocolate
I read with great interest this review study titled: “Cocoa, Glucose Tolerance, and Insulin Signaling: Cardiometabolic Protection” and published in the Journal of Agriculture and Food Chemistry by Ferri el al. The authors expand on a key ingredient in cocoa, a flavonol known as oligomeric procyanidins. This particular antioxidant has protective properties against obesity and diabetes, making dark unprocessed chocolate the perfect desert for our patient population. Dark chocolate as opposed to milk chocolate is higher in cocoa content. It is more bitter than milk chocolate due to the higher content of flavonols. Highly processed chocolates like white chocolate have no flavonols at all and lack therefore the cardio-metabolic protective effects of cocoa. Most American chocolate is highly processed, and rich in vegetable oil, sugar and preservatives. We encourage our bariatric patients to avoid candies, and other sweet items before and after weight loss surgery. Sugar addiction is a real and common problem we encounter on a daily basis at Houston Weight Loss and Surgery Center. Overcoming the sweet tooth habit is a difficult hurdle to most of us. One way for curbing our appetite for sugar is to snack on dark chocolate. Consuming dark chocolate in moderation and on a daily basis reduces insulin resistance, decreases appetite, lowers blood pressure and prevents weight gain.



Experiments in mice maintained on different diets, showed that adding cocoa flavonol made the biggest difference in improving glucose tolerance and keeping the mice weight down. The effect of cocoa falvonol on gastrointestinal motility as well as neuro-endocrine hormone secretion like GLP-1 and Ghrelin has not been studied yet. We hope future studies will evaluate this potential interaction as it may be used as an effective weight loss and diabetes medication. For now however, we encourage our patients to enjoy dark unprocessed chocolate to improve their health before and after bariatric surgery

#### Houston Weight Loss Surgery Center recommends: Bariatric Pizza
Gastric sleeve and gastric bypass patients have limited stomach capacities. Meal size is small and priority is given to get protein first. Bariatric surgery patients can and should eat regular food. Food that is healthy, nutritious and also enjoyable. At Houston Weight Loss Surgery Center we enjoy pizza and our patients are no exception. The only caveat is that traditional pizza, even thin crust pizza, has too much bread to digest if you have had gastric sleeve or bypass surgery. Furthermore, most pizza toppings may include fatty cuts of meat like pepperoni or bacon and hefty quantities of melted cheese that you don’t need to consume. Most commercial pizza sauce contains sugar and lots of it. The good news is that you can make your own tomato sauce using the ingredients you like. All you need is a blender, tomatoes (canned or fresh), salt and pepper, and I like to add garlic (lot of garlic) and fresh or dried basil, oregano and or thyme. Blend everything then cook over fire until you reduce the sauce and it becomes thick enough to spread on pizza dough. The dough is key here. Bariatric dough is not made out of wheat flour. The healthier and lighter dough alternative is made with sprouted grains like quinoa. Soak quinoa in water for 8 hours. Then drain the water and blend the sprouted quinoa grains with baking powder and water to make the dough. For more details check this recipe from cooking light magazine http://bcove.me/dvvm74ib
Quinoa is Houston Weight Loss Surgery Center’s most popular Superfood. It is a highly nutritive food rich in proteins, heart healthy monounsaturated fat (Oleic acid), minerals and two powerful anti-oxidants in the form of flavonoids: Quercetin and Kaempferol. Quinoa consumption is perfectly suited to fight obesity. Research in rats has shown that daily quinoa consumption reduces inflammation in fat and intestinal lining cells.

#### Houston, we have a weight loss problem?
JAMA, the journal of the American medical association describes our time as “The age of obesity and inactivity” and we all know it:

2/3 of adults and 1/3 of children and adolescents are now classified as obese or overweight.
The cost of treatment of obesity related conditions has reached 10 % of the total US medical expenditure.
Obesity is reversing all the gains made in the past 100 years by lowering cholesterol, hypertension and smoking rates.

What We Should Do?
The answer is simple: Eat Less and exercise more. 25% of American men and 43% of women attempt to lose weight each year. Of those who succeed 5 % manage to keep it off for the long haul. 45 million Americans belong nowadays to a health club as opposed to 23 million in 1993. $19 billion per year are spent on gym memberships. A Houston heart survey showed a 10% increase in regular exercise from 1980 till 2000. Yet, obesity figures in Houston more than doubled in that same time frame.
Why is our body fighting against our own good health?
In an article published in 2011 in the New England Journal of Medicine, Dr. Proietto, from the University of Melbourne, showed that multiple compensatory mechanisms encouraging weight gain, persist for at least 1 year after weight loss. He followed 50 overweight individuals for approximately one year after putting them on a very low calorie diet for several weeks. Hunger and satiety hormones were monitored. Dr. Proietto showed that following diet induced weight loss, hunger hormones go up and satiety hormones go down. In other words, every time you lose some weight following any kind of diet you feel hungrier than before. The more you lose weight the harder it is to maintain a low calorie diet. Furthermore, your metabolism goes down as you lose weight. Your body goes into an energy conservation mode making it harder to shed additional pounds. In this fight between you and your own body, guess who wins? 95% of all those who attempt to lose weight by diet and exercise end up gaining it back. The reality is that very few of us can overcome our basic biology to maintain the weight loss.
At Houston weight loss surgery center, we clearly differentiate between preventing weight gain and treating excess weight. We strongly recommend eating less and exercising more to stay fit, and healthy. If however you are already overweight, weight loss surgery is the only effective treatment for durable weight loss. Bariatric surgery prevents the compensatory changes that accompany weight loss. You are no longer fighting your own body. The struggle against obesity becomes a journey. A journey, we are privileged to be part of. If you are overweight and you are trying to lose weight please give us a call at 281.205.3205

#### How Do I Manage Advanced Gastroduodenoparesis?
A colleague presented this case on the SAGES Foregut Surgery Masters Program Collaboration:
70 year-old-male with history of esophageal perforation from a Boerhaave rupture, who had repair and omental patch about 4 years ago. Had progressive nausea, vomiting and epigastric pain after that, ultimately diagnosed with gastroparesis, likely vagal nerve injury. Also later diagnosed with SMA syndrome, which I suspected was from weight loss secondary to gastroparesis. He did well with a GJ tube, and I had him set up for pyloromyotomy but he cancelled because he was feeling so well after gaining some weight with the tube. Now it’s several months later and he’s feeling bad and losing weight again. I’ll be replacing his GJ tube for sure. My questions: if considering surgery, would you address both the SMA syndrome and GP at the same time, or treat GP alone and see how he does? I fear that his J shaped stomach will not respond all that well to pyloromyotomy but have no data to back that up. He’d be a poor candidate for subtotal gastrectomy I think (CHF, EF 30%).

This patient has advanced gastroduodenoparesis resulting in a dilated stomach and duodenum without any mechanical obstruction of the duodenum as is typically the case with SMA syndrome. The treatment for this rare condition must target gastric motility. Rather than performing a subtotal gastrectomy or bypassing the stomach with a Roux-en-Y gastric bypass, a modified sleeve that preserves the antral pump is an excellent solution. I have developed this approach several years ago and I have personally applied it on several patients with great results. I published a case report in SOARD in 2012 to illustrate my approach ( https://www.ncbi.nlm.nih.gov/pubmed/22963822).

Mechanical drainage of the stomach with a pyloroplasty or wide gastro-jejunostomy does not work in general for gastroparesis and in particular for advanced gastroduodenoparesis.

The mechanism behind gastric motility improvement that results from resecting the greater curvature is not well understood. It is possible that stomach motility recovers by resecting the cells of Cajal or gastric pacemakers, typically located along the greater curvature. I think that gastroparesis is associated with emptying disorders of the Magenstrasse pathway. A modified gastric sleeve resection reestablishes this pathway.

Understanding gastric motility and its underlying neuro-hormonal mechanism, in health and disease, is crucial to improving our care of patients with obesity, diabetes, GERD and diabetes.

#### How Does Bariatric Surgery Work? A New Review Article
I read with great interest the recently published review article “Mechanisms in bariatric surgery: Gut hormones, diabetes resolution, and weight loss” by Holst et al. The study is published in Surgery for Obesity and Related Diseases journal, May 2018 issue. The authors presented a thorough and clear review on weight loss mechanisms following bariatric surgery like gastric bypass and gastric sleeve procedures. Holst and colleagues present evidence supporting accelerated nutrient passage from gastric pouch into intestines as well as nutrient absorption across gut mucosa into the blood stream. This accelerated nutrient delivery including glucose and amino acids stimulates postprandial neuroendocrine hormone secretion like GLP-1 and PYY. Within few days after weight loss surgery, GLP-1 an insulinotropic hormone and glucose plasma levels dramatically rise, creating a powerful stimulus for pancreatic beta cells. Beta cells sensitivity to glucose is enhanced and postprandial insulin secretion increases leading to improvement in postprandial blood sugar control. Administration of exendin 9-39, a GLP-1 antagonist, impairs the rise in insulin secretion and improvement of glucose homeostasis. Such evidence confirms the central role of neuroendocrine cells and GLP-1 in particular in bariatric surgery mechanism of action. The concepts of restriction and malabsorption that have been traditionally assigned to Roux-en-Y gastric bypass are no longer applicable. Indeed, studies quoted in this article have clearly demonstrated increased gastric pouch emptying and increased nutrient absorption.

The implications of such findings are significant when it comes to optimizing surgical technique. The most effective weight loss procedure is the procedure that accelerates gastro-intestinal motility the most. We no longer use the smallest size bougie to perform a sleeve gastrectomy. A smaller bougie is associated with higher leak rate without concomitant improvement in weight loss outcomes. The most optimal sleeve shape is the one that preserves certain stomach components that accelerate gastric emptying. These components include preserving the antrum (gastric pump), avoid narrowing the incisura angularis, and resecting the redundant posterior gastric fundus. The same applies to gastric pouch size in Roux-en-Y gastric bypass surgery and the futile practice of endoscopic narrowing of gastro-jejunostomy in hope of increasing gastric pouch food stasis. Food stasis is, indeed, not associated with increased satiety and weight loss.

Several years ago, I developed gastric fundus invagination as a weight loss procedure. It preserves stomach structure but at the same time eliminates gastric fundus meal accommodation. As a result, gastric fundus invagination increases gastric emptying and may possibly increase GLP-1 secretion. We don’t know if, and, how gastric fundus invagination changes pacemaker function and stomach electric activity. Does gastric fundus invagination restore emptying along the Magenstrasse pathway? Magenstrasse emptying depends on both electric waves generated in the fundus and antrum. By invaginating gastric fundus in close proximity to stomach antrum, what happens to those waves?

Metabolic and weight loss surgery research is much needed today to elucidate the role of gastro-intestinal motility in disease like obesity, type Diabetes, GERD and gastroparesis. Understanding gastro-intestinal motility may help develop more effective and less invasive solutions for diseases that have reached epidemic level in our society.

#### Hurricane Harvey: Together We Heal
We have witnessed unprecedented flooding and destruction over the past few days. Harvey, a storm of epic proportions, has affected the lives of nearly 5 million Houstonians. In two days, over 50 inches of water were unloaded over the greater Houston area. Many families had to evacuate their houses leaving everything behind.

Our thoughts are with our patients and our teams affected by the flooding. Houston, however, will recover very soon. I have witnessed firsthand the resilience, compassion and courage of Houstonians. There is still much work to be done but we will get through this together.

We are planning to reopen our offices this coming week. We appreciate your patience, and ask you to please bear with us as our phone lines may be busy and some of our team members may not be working.

Warm Regards,
Elias Darido, MD

#### I Never Had Reflux Before My Gastric Sleeve.
Erika from Houston sent us this question: “Hello, I am about to have the gastric sleeve surgery in a week. I don’t suffer from acid reflux; however, my mother had the gastric sleeve and does suffer from awful acid reflux. She had her sleeve surgery performed in Houston, but currently resides in New Braunfels, Texas. She suffers from pneumonia every so often at 44 years old and they are worried it may have been worsened by her surgery/ acid reflux issue. I am worried that my mom may end up with Pulmonary Fibrosis if she does not seek proper medical treatment to control the acid reflux. Please help!”
Dear Erika,
A poorly performed sleeve gastrectomy invariably results in acid reflux. Aggressive stomach resection results in functional gastric sleeve lumen obstruction. Functional obstruction of gastric sleeve drives acid backflow into esophagus. Acid reflux causes a hiatal hernia to gradually develop, and hiatal hernia development weakens acid reflux barrier.
The result is progressive acid reflux disease with worsening heartburn, food regurgitation, pain, cough and sore throat. Despite weight loss after sleeve gastrectomy, and resolution of obesity related morbidities, patients have poor quality of life due to severe reflux. Fortunately, several solutions are available to alleviate acid reflux after sleeve gastrectomy. Central to these treatment options is a comprehensive workup to confirm and stage GERD. Workup helps elucidate size of hiatal hernia and anatomy of gastric sleeve. At Houston Weight Loss Surgery Center and Houston Heartburn and Reflux Center most patients presenting with acid reflux after sleeve gastrectomy are treated with hiatal hernia repair. The minority of patients with severe narrowing of gastric sleeve lumen require, in addition to hiatal hernia repair, conversion of sleeve gastrectomy to gastric bypass.
Fortunately, over the past 5 years, we have witnessed a gradual decrease in the proportion of patients requiring sleeve to bypass conversion as more bariatric surgeons are aware of the consequences of narrowing gastric sleeve lumen.

#### In Defense of Food
In Defense of Food shows us how, despite the daunting dietary landscape Americans confront in the modern supermarket, we can escape the Western diet and, by doing so, most of the chronic diseases that diet causes. We can relearn which foods are healthy, develop simple ways to moderate our appetites, and return eating to its proper context — out of the car and back to the table. Michael Pollan’s bracing and eloquent manifesto shows us how we can start making thoughtful food choices that will enrich our lives, enlarge our sense of what it means to be healthy, and bring pleasure back to eating.

#### Insufficient Weight Loss after Gastric Sleeve Surgery
Gastric sleeve surgery is currently the most commonly performed weight loss procedure in Houston. With this increase in gastric sleeve popularity, we have witnessed a rising number of patients with insufficient weight loss following gastric sleeve surgery. Weight loss following any bariatric procedure like sleeve gastrectomy and gastric bypass surgery varies among patients. Percent excess body weight loss follows a bell shape curve. Patients who are poor responders to gastric sleeve surgery are candidates for either Roux-en-Y gastric bypass surgery, or duodenal switch procedure. Gastric sleeve conversion to either gastric bypass or duodenal switch is a straightforward surgery since no bridges are burnt. The question, however, is which revision procedure is best recommended?

Gastric bypass surgery and sleeve gastrectomy are almost equally effective in terms of weight loss and comorbidity resolution. Both procedures accelerate gastro-intestinal motility and increase post-prandial neuro-endocrine secretion of GLP-1 and PYY. Studies in rodent models have demonstrated increased metabolic rate after gastric bypass but not gastric sleeve surgery. In humans, however, gastric bypass surgery does not seem to increase the metabolic rate. Accordingly, gastric sleeve conversion to gastric bypass, in poor responders, is less likely to improve weight loss. At Houston Weight Loss Surgery Center, we favor gastric sleeve conversion to duodenal switch in theses cases. Duodenal switch surgery is the most effective weight loss procedure associated with the highest rate of diabetes resolution and percent excess body weight loss. Duodenal switch mechanism of action differs from that of gastric bypass and sleeve surgery. Duodenal switch is more likely to benefit non-responders to gastric sleeve surgery than gastric bypass. Duodenal switch procedure is technically more demanding than gastric bypass or sleeve surgery. Duodenal switch causes nutrient and vitamin malabsorption. Non-compliant patients may not be the best candidates for duodenal switch surgery.

Of note, a poorly performed gastric sleeve resulting in poor weight loss is best converted to gastric bypass. Typically, a poorly performed gastric sleeve is associated with a narrowed incisura angularis, dilated or retained gastric fundus and acid reflux. In such situations, we strongly advocate the conversion of sleeve to gastric bypass to stop acid reflux and improve weight loss.

#### Insulin Resistance, Pre-Diabetes, and Sleeve Gastrectomy
Insulin is a hormone produced by the pancreas to regulate blood sugar levels. Insulin rises after eating to promote sugar uptake by different types of cells in the body.
Muscle cells use sugars for energy production. Liver cells convert sugar to glycogen. While fat cells convert excess sugar to fat.
During fasting and exercise, insulin levels drop to allow glycogen and fat breakdown to be used for energy production.

What Is Insulin Resistance?
Insulin resistance occurs when cells become less sensitive to insulin, forcing the pancreas to secrete more insulin to maintain normal blood sugar levels. When the pancreas can no longer keep up with the increasing insulin demand, a condition called pre-diabetes occurs.
Patients with pre-diabetes have elevated blood sugar levels. Blood sugar level is still not high enough to be diagnosed as type 2 diabetes.
Over time, as insulin resistance worsens, pre-diabetes develops into type 2 diabetes.

Causes of Insulin Resistance and Risk Factors
The exact causes of insulin resistance are still not fully understood. However, central obesity (visceral fat), physical inactivity, and a diet of highly processed foods are strongly associated with insulin resistance.

The Role of Visceral Fat in Insulin Resistance
Central obesity, also known as increased visceral fat, is due to excess fat accumulation in the liver, pancreas, and around the intestines. Visceral fat increases inflammation that impairs liver and pancreas function and leads to insulin resistance.

Lifestyle Factors That Contribute to Insulin Resistance

 	Lack of exercise
 	Chronic stress
 	Diet high in refined carbohydrates

These factors contribute to visceral fat accumulation and insulin resistance.

How to Reduce Insulin Resistance
You can reduce your insulin resistance before you develop type 2 diabetes.

Lifestyle Changes to Improve Insulin Sensitivity

 	Reduce stress
 	Exercise daily
 	Adopt a low-carb, vegetable- and protein-rich diet
 	Avoid high glycemic index foods

High glycemic index foods, such as wheat-related products like bread, pasta, cake, and cookies, cause your blood sugar to rise quickly.

Working With a Nutritionist
Our bariatric nutritionist can help you replace high glycemic index food items like rice, potatoes, high-sugar drinks like juices and sodas, and breakfast cereals with nuts, non-starchy vegetables, berries, and fish.

Medical Options for Managing Insulin Resistance
If lifestyle changes are not enough to help reduce your insulin resistance, medications and surgical options may be considered.

Medications for Insulin Resistance
If lifestyles changes are not enough to help reduce your insulin resistance, medications like Metformin and Ozempic are often used to reduce appetite, promote weight loss and improve insulin sensitivity.

Gastric Sleeve Surgery for Severe Insulin Resistance
If your BMI is more than 35, gastric sleeve surgery is a safe and reliable tool to reduce your appetite, lower your weight and your insulin resistance.
For additional information on reversing insulin resistance, preventing type 2 diabetes, and improving your health, give us a call at 832-963-1803.

#### Insurance-mandated medical weight management before bariatric surgery
“Insurance-mandated medical weight management before bariatric surgery” by Manish Parikh, M.D. et al from the department of Surgery of New York University Langone Medical Center. This interesting study is published in the current issue of SOARD. It assesses the effect of insurance mandated medical weight loss programs on weight loss outcomes after bariatric surgery. A total of 1432 patients were analyzed retrospectively including a control group of 560 patients. There was no weight loss difference between both groups at one and 2 year follow up.

There is no doubt that patient education prior to bariatric surgery is crucial. Obesity is a lifestyle disease. Almost all patients I see in my practice presenting for gastric sleeve or bypass surgery consume junk and processed food on daily basis. They have no time to cook at home and very little time to exercise. They skip breakfast and eat heavy rich food at night. Many use food as a coping mechanism and are addicted to sugar in the form of soda, sweet tea or candies. Obviously, there is a role for education here. Some patients require one or two educational visits and others will never learn how to change their habits and lifestyle. Those who don’t learn or are not capable of changing their habits and daily living do not qualify for bariatric surgery even after they meet the insurance requirement for pre-operative medical weight loss.

This study proves that the insurance requirements are rigid, ineffective and not suitable for every patient. I would rather see the insurance companies create lifestyle programs that promote healthy eating and living. Through these programs patients are screened and referred to bariatric surgery if found appropriate. Bariatric surgery is currently the most effective treatment for obesity. It is a durable solution especially when patients adheres and adopts healthy eating and exercise habits. Gastric bypass and sleeve procedures save lives, resolve comorbidities and ultimately save money for both insurance companies and government. Insurance companies, public health officials and the federal government should work together to promote effective weight loss solutions and most importantly preventative measures to curb the obesity epidemic. Unfortunately, we are still dabbling with archaic rules and regulations that make no sense and are preventing qualified patients from getting the care they deserve.

Finally, I would like to emphasize the importance of post-operative follow up and supervised medical weight loss. Obesity is a chronic disease and weight loss is a lifetime battle. Bariatric surgery gives you the edge in this battle but you must keep fighting weight gain even after successful weight loss surgery.

#### Interesting Case: Severe Acid Reflux After Gastric Sleeve Surgery?
The patient is a 51-year-old female who underwent a gastric sleeve in 2006 at one of the hospitals in the medical center in Houston. She lost around 30 pounds during the first year after surgery and maintained around 25 pound weight loss over the past 10 years. The patient reports that prior to surgery she experienced heartburn at least twice weekly and food regurgitation from time to time. Prior to surgery she was not evaluated for acid reflux disease by endoscopy, barium swallow or pH Bravo capsule. During surgery, her hiatal hernia that may have been smaller at the time was not investigated. The operative report mentions that of a 36 French bougie was used to perform the gastric sleeve.
Shortly after surgery and for the past 10 years the patient has been struggling with severe acid reflux related symptoms including heartburn and food regurgitation. She reports nighttime symptoms that prevent her from sleeping with fatigue and somnolence during the day. As usual the patient was placed on escalating doses of PPIs in hopeless attempts to control her symptoms. Following presentation to my office, she underwent an upper endoscopy that showed a sliding hiatal hernia and laxity in the hiatal opening. The distal esophagus was inflamed despite high dose PPI. The gastric fundus was incompletely resected and there was no narrowing at the incisura. An UGI showed obvious contrast reflux into the esophagus, and a large gastric fundus where contrast pooled and slowly passed into the distal stomach.
It became readily apparent that the patient had an incompletely resected gastric sleeve that lead to poor weight loss and acid reflux. The problem is anatomic and the treatment is surgery rather than high dose PPIs. Indeed, a well-performed gastric sleeve surgery effectively eliminates acid reflux. However, an incomplete gastric sleeve resection is a sure recipe for acid reflux disease or GERD. Narrowing or twisting the gastric sleeve tube at the level of the incisura also results in acid reflux. A hiatal hernia further contributes to the reflux pathophysiology.
I have encountered several cases so far in my career of sleeve induced acid reflux. Invariably, a retained gastric fundus was present. Mechanical or functional narrowing of the incisura does contribute to acid reflux and food regurgitation. However, in this particular case the incisura was widely open on endoscopy and UGI. The gastric fundus seemed to be the main culprit especially with a widely open hiatus. A retained gastric fundus may contribute to intermittent relaxation of the lower esophageal sphincter leading to reflux. Furthermore the gastric fundus may allow for an acid pocket to form in the vicinity of the gastric cardia leading to acid reflux. A retained gastric fundus may also cause delayed gastric emptying further exacerbating acid reflux. The gastric fundus is a posterior structure and it can easily be incompletely resected during sleeve surgery. When properly resected, acid reflux resolves. Fixing the hiatal hernia alone is not enough. A wide hiatal opening and the presence of a sliding hernia are two factors that contribute to acid reflux. They are not however the only or most important factors. In this particular case, I performed a hiatal hernia repair with gastric fundus resection. Patient was very satisfied after surgery with complete resolution of her acid reflux related symptoms. She also lost 46 more pounds in 6 months. Other cases with narrowing of the incisura were converted to gastric bypass with excellent acid reflux resolution. LINX procedure for acid reflux cases after sleeve surgery has been reported. It is obvious that in this particular case LINX surgery is completely useless. In general, I don’t think that LINX surgery has any role in treating any form of acid reflux disease. Hopefully, future studies will demonstrate my point of view.

#### Intermittent Fasting and Weight Loss
In this day and age of excessive calorie consumption, sedentary lifestyle and associated obesity, intermittent fasting, IF, seems like a much-needed solution. Stopping food intake for certain periods of time allows the digestive system, brain and other organs to take a break from metabolizing ingested calories. Food digestion, absorption and metabolism, though much needed to survive, are a taxing function on a number of organs. The consumption of rich meals in fat and carbohydrates and the constant snacking on calorie dense, highly processed food items can overrun mitochondrial energy processing. When mitochondria don’t operate efficiently, they generate free radicals that result in oxidative stress. Free radicals are unstable molecules that damage cells, increase inflammation, and shorten survival. Oxidative stress is suspected to play an important role in chronic diseases like atherosclerosis, Alzheimer and Parkinson disease. Studies in rodents have clearly shown increased longevity in association with reduced calorie intake. Whether the same applies to humans or not is still unknown. One thing for sure, our bodies have evolved over thousands of years of hunger and famine. We are efficient at conserving calories, and we are adapted to fast and survive prolonged periods of calorie restriction. “There is nothing else you can do to your body that is as powerful as fasting”, concluded Dr. Michael Mosley, author of The FastDiet book. The benefits of IF in Mosley’s book go beyond simple calorie restriction and weight loss. IF stimulates autophagy; the non-inflammatory process that destroys and eliminates old and damaged cells. IF switches on repair genes that rejuvenates the immune system. The effects of IF are long lasting and result in durable weight loss, improved blood sugar control and decreased cholesterol and blood insulin levels.

Fasting is hard to start and difficult to maintain. There are a number of protocols in the literature you can follow. I prefer to fast along the circadian rhythm. I start by skipping dinner and loading my calories in the morning. I then fast from early afternoon till early morning for a period of 15 to 17 hours. The circadian rhythm is a master clock that regulates the sleep /wake cycle and optimize energy metabolism. During the sleep cycle our body favors fasting with increased lipid catabolism and liver gluconeogenesis. During the wake cycle, insulin synthesis increases promoting glycogen formation and lipogenesis. Feeding during the sleep cycle disrupts the circadian clock and increase oxidative stress. Dr. Mosley advocates the 5:2 diet in his book The FastDiet which entails fasting for two days of the week. Others prefer to skip breakfast and lunch and consume one meal a day around dinner time. This pattern is particularly common for individuals following the keto diet.

In summary, Intermittent Fasting may have a number of health-related benefits. IF is particularly relevant to overweight, and insulin resistant individuals. The majority of adults in Houston are overweight, and with type 2 Diabetes on the rise, IF may be a powerful survival tool.

#### Intermittent Fasting: Beyond Weight Loss
I read with great interest the review article on intermittent fasting recently published in the New England Journal of Medicine. The authors start by showing that numerous studies in animals have shown increased lifespan with calorie restriction. Chronic disorders like obesity, diabetes, and cancer respond to intermittent fasting. The assumption was that calorie restriction reduces oxygen free radical production and consequently reduces cellular damage. Weight loss, however, and reduced free-radical production secondary to intermittent fasting on partly explains fasting numerous benefits. Intermittent fasting activates pathways that improves glucose regulation, increase stress resistance, and suppress inflammation. During fasting, triglycerides are converted to ketones bodies in the liver. Ketone bodies are used by organs as fuel. However, ketone bodies are not just fuel. They are signaling molecules with effect on major cellular pathways that influence health and aging. The exact mechanisms of intermittent fasting beneficial effect on our health are not fully understood. There is plenty of evidence, however, to recommend intermittent fasting for our bariatric and weight loss patients. There are a number of intermittent fasting protocols. I prefer and personally adopt daily time restricted feeding. I limit my food intake to 6 hours a day and fast for the remaining 18 hours. Others have found 5:2 intermittent fasting regimen more practical. In this regimen, calorie intake during 2 days of the week is restricted to 500 calories a day.

The authors conclude that combined with exercise, intermittent fasting results in many long-term adaptations that improve “mental and physical performance and increase disease resistance”.

#### Intermittent Vagal Nerve Blockade For Morbid Obesity
VBLOC therapy or intermittent vagal nerve blockade is a novel weight loss procedure that was recently approved by the FDA. The device is very unique as it targets the nervous connection between the brain and gastrointestinal system, the vagus nerve. Both anterior and posterior vagal trunks are encircled with special electrodes attached to a generator. The generator is implanted subcutaneously. Intermittent electrical pulses block the vagus nerve function. The vagus nerve is involved in gastric emptying and sending signals to the brain about stomach fullness. The specific mechanisms for weight loss due to the device are not known.

EMPOWER is a prospective randomized double blind controlled trial that enrolled around 500 patients with average BMI at 41. The main outcomes of the study were device safety and percent excess weight loss 12 months after implantation. The results showed no difference in weight loss between treated patients and controls and the device was found to be safe.

A similar clinical trial that included 233 patients with a BMI of 35 or greater found 8.5 percent more weight loss in treated patients compared to controls. The clinical study did not meet its original endpoint, which was that the experimental group loses at least 10 percent more excess weight than the control group. Still the FDA approved the device claiming that the benefits of VBLOC outweighed its risks. Additionally, the FDA sponsored a survey relating to patient preferences of obesity devices. The survey showed that some patients accept risks associated with VBLOC for the amount of weight loss expected to be provided.

In other words, the FDA approved a device for weight loss of questionable efficacy and unknown mechanism of action based on a patient survey. Patients are encouraged to actively participate in their medical care especially when it relates to obesity and bariatric surgery. However, patients need to be clearly and fairly educated about the efficacy of different weight loss procedures. Newer weight loss procedures using endoscopic techniques like intra-gastric balloon or neuro-modulation like VBLOC don’t seem to be effective weight loss solutions. Obese patients with type-2 diabetes and other obesity related comorbidities are unlikely to benefit from such interventions. Patients interested in significant and durable weight loss are most likely not going to be successful having a balloon in their stomach for 6 months. I am concerned for bariatric and acid reflux patients falling victims of inaccurate advertisement and exaggerated expectations. I hope the FDA would exert more caution before approving these devices.

#### Is Barrett’s Esophagus a Contraindication for Sleeve Gastrectomy?
Laura from Houston Sent us this question:

“Hello. I have a BMI of 32.6 and high blood pressure, which has landed me in the ER twice this year. Additionally, I was diagnosed with Barrett’s esophagus over a decade ago and have been treated with PPIs and monitored regularly. Although I do not meet the criteria for weight loss surgery for insurance, I am interested in off label (self-pay) for the sake of my health. I have tried many times to lose weight without success. The gastric bypass has been recommended to me in lieu of the sleeve, but that seems quite extreme for my BMI. I am very interested in your thoughts on this, given your knowledge of reflux and bariatric surgery. Both of my grandmothers died of strokes early in life, and I am very concerned about my health as I near 50. I appreciate your thoughts and have greatly appreciated your blog and research as well. Thank you!”

Dear Laura,

I greatly enjoyed your question. Thank you for sharing with us your health concerns and a medical problem with no clear guidelines to address it. First, allow me to mention that BMI criteria for weight loss surgery are outdated. Our weight loss surgery complication rate is very low. For someone, with BMI between 30 and 35 and two comorbidities (uncontrolled hypertension and Barrett’s esophagus) who is struggling to lose weight and failing to achieve durable and significant weight loss, weight loss surgery is indicated.

Second, I agree with you that gastric bypass, while effective and safe, is slightly more aggressive than gastric bypass especially for someone with a lower BMI. Gastric sleeve surgery is an equally effective weight loss procedure but less invasive than gastric bypass. Gastric sleeve surgery is not associated with long-term complications like marginal ulceration and internal hernias.

A number of published studies have shown increased acid reflux after gastric sleeve surgery. A meta-analysis of 46 studies including 10718 sleeve gastrectomy patients was recently published in the Annals of Surgery journal. The study shows a 19% increase in post-sleeve gastrectomy GERD and 23% new onset acid reflux. Long-term prevalence of esophagitis was 28% and Barrett esophagus was 8%. 4% of all patients required conversion to gastric bypass for severe reflux.

At Houston Heartburn and Reflux Center, my sleeve gastrectomy outcomes have been different. I have found that a properly performed sleeve gastrectomy in conjunction with a properly performed hiatal hernia repair lead to acid reflux resolution. Gastric sleeve lumen must be uniform with no narrowing or twisting. Herniated stomach and distal esophagus must be reduced into the abdominal cavity and initial normal anatomy restored. Gastric antrum must be preserved to promote gastric emptying. All my sleeve gastrectomy patients, with proven acid reflux, have reported complete acid reflux symptom resolution immediately following sleeve gastrectomy and prior to any significant weight loss. Most published studies that shown increased acid reflux after sleeve gastrectomy do not comment on the presence or absence of hiatal hernia, gastric sleeve lumen narrowing… If we control for these variables will post-operative acid reflux symptoms and incidence decrease?

Furthermore, patients who underwent sleeve gastrectomy somewhere else and presented to Houston Heartburn and Reflux Center for evaluation of acid reflux have invariably been found to have hiatal hernias. Those patients with no narrowing of gastric sleeve lumen, underwent hiatal hernia repair resulting in complete acid reflux symptom resolution. Consequently, over the past 5 years, I have come to the conclusion that a properly performed sleeve gastrectomy/hiatal hernia repair is an effective anti-reflux procedure. Does the same apply to Barrett’s mucosa? Unfortunately, I don’t have any data or personal experience with patients with Barrett’s esophagus undergoing sleeve gastrectomy at Houston Heartburn and Reflux Center. One would assume that Barrett’s esophagus is likely to improve or stabilize after sleeve gastrectomy if acid reflux is cured, but studies are needed to confirm such an assumption. Furthermore, if Barrett esophagus progresses to cancer and resection is needed, the remaining stomach is used as a conduit to replace the resected esophagus. Sleeve gastrectomy eliminates this option should the patient need esophageal cancer resection. I should mention that we currently have effective noninvasive and endoscopic treatment options for Barrett’s esophagus that ablate Barrett’s mucosa before it progresses to cancer. Consequently, if you have Barrett’s esophagus, you are most likely to continue periodic surveillance. Your chances of progressing to esophageal cancer are low.

Recently, a group of surgeons from France developed a procedure called the N-sleeve. The procedure is a hybrid of Nissen fundoplication and sleeve gastrectomy. A Nissen fundoplication is first constructed then a sleeve gastrectomy is added below the wrap. The published study shows good early weight loss results and excellent acid reflux control. Additional studies are needed to corroborate these findings.

Back to your question, what is the best weight loss procedure in your case? Would I offer sleeve gastrectomy to a patient with Barrett’s esophagus? I don’t think there is a clear answer or guideline. The general consensus is to offer gastric bypass for patients with Barrett’s esophagus. I don’t agree with the general consensus and I think Barrett’s esophagus is likely to improve and/or not progress to cancer following sleeve gastrectomy. This is my personal opinion. Should acid reflux worsen after sleeve gastrectomy (I have not yet seen this with my own patients), gastric sleeve to bypass conversion can be easily performed.

#### Is ESV Indicated for VSG Revision?
Pamela from Houston sent us a question inquiring about the use of ESV or endoscopic sleeve gastroplasty as revision surgery for weight regain after VSG or sleeve gastrectomy. To start, ESV is a poor primary weight loss procedure. ESV is a purely restrictive procedure that does not alter stomach and intestinal hormones that control food intake, appetite, and satiety as well as insulin resistance. VSG on the other hand, is a metabolic procedure that alters gastrointestinal hormone secretion in response to food intake to favor weight loss. Contrary to popular belief, weight regain after VSG is not secondary to gastric sleeve stretching. Rather, weight regain after VSG occurs because of loss of these gastro-intestinal hormones that favor weight loss. Hormones like GLP_1 and PYY increase after VSG leading to decreased insulin resistance, increased satiety, decreased appetite… When VSG patients return to old unhealthy eating habits, they damage the same hormones that helped them lose weight initially. Slowly, they start overeating and gaining weight. In the process, the sleeve lumen stretches. Hence, the increase in sleeve size is a consequence rather than a cause of weight regain.
Therefore, reducing the stretched gastric sleeve size, endoscopically via ESV, or laparoscopically via redo VSG, is not associated with significant weight loss. At Houston Weight loss Surgery Center, we do not recommend Endo-sleeve, or re-sleeve, for weight regain after sleeve gastrectomy.

#### Is Food Consumption Changing in the US?
Major food companies like Kraft Heinz, Nestle, Campbell Soup and J.M. Smucker are reporting weak sales in the US market. American consumers are turning to healthier meals and snacks. The demand for fresh and healthier food is rising and food makers are struggling to adapt. For many years, processed food rich in sugar, salt and hydrogenated fat has been easy and cheap to produce and sell. Hard pressed consumers living in a fast pace modern life were easily sucked in the “buy one get one free” promotions for TV dinners. As processed food replaced traditional food home cooking vanished. Americans spend less time cooking than any other developed country in the world according to the Organization for Economic Cooperation and development. Indeed, most of our weight loss patients presenting for evaluation at Houston Weight Loss Surgery Center don’t have time for cooking, don’t know how to cook or simply hate cooking. A study published in the Harvard Business Review showed that one in 10 Americans enjoys preparing dinner. The reality is Houstonians would rather eat out or order delivery instead of cooking dinner. When preparing the simplest meal is a hassle, however, weight loss, as well as maintaining weight loss following bariatric surgery, become a more difficult challenge.

"Fresh prepared foods" are meals prepared and served at grocery stores like Central Market in Houston. According to, Supermarket Guru, a market research firm, sales of such foods are about $25 billion annually in the US. Freshly prepared meals may contain less salt and preservatives than processed and fast food, but they are no match to home cooking. I have personally tried a number of salads offered at Central Market in Houston. The taste is great but the content is not. These salads are loaded with sugar, oil, and artificial flavors. You think you are having a light and healthy lunch. When I looked at the label, however, and I counted the calories of a small or medium size salad, I was surprised. Take one of my favorite, kale, cranberry and pepita salad that Central Market offers in Houston. One would assume that this is a low-calorie meal rich in green plant fiber. The salad, however, is loaded with sugar, sesame oil, Soya sauce, salt… to make it taste better and entice you to buy it more often. No wonder why my home-made kale salad that contains the same basic ingredients: kale, pepita and cranberries doesn’t taste as good. My dressing is basic, simple and low calorie: olive oil, mustard, lemon juice and a pinch of salt. Central Market salad dressing has twenty more ingredients including generous amounts of sugar. Restaurants and grocery stores don’t care about your health and weight loss goals. Their primary purpose is to sell you more by entertaining your taste buds. You don’t crave boring, high fiber, low-calorie food, and most likely, you won’t buy more than once. There is simply no room for healthy food items on your grocery store shelves or anywhere else outside your own kitchen.

The loss of home cooking in America, over the past 50 years, has no doubt fueled the Obesity epidemic we are currently witnessing. So far, there is no HEALTY alternative to home cooking and meal prepping. If you are contemplating weight loss surgery, your first and most important step in your weight loss journey is to embrace home cooking as part of your daily life.

#### Is Gastric Sleeve Surgery The Right Choice For Me?
Gastric sleeve surgery is currently the most commonly performed bariatric procedure in the US and the world. It is less invasive than gastric bypass and much more effective than lap band. When properly performed, gastric sleeve is safe and has minimal long-term complications. The most important step in gastric sleeve surgery is complete gastric fundus resection. Retained gastric fundus leads to poor weight loss results and most importantly to severe acid reflux. Complete take down of all short gastric vessels and full visualization of the left crus are key steps to mobilizing the posterior fundus.

For years, bariatric surgeons have debated the size of the bougie used to resect the stomach. A number of non-sense guidelines and recommendations were issued with little relevance to the underlying physiology of gastric sleeve and its metabolic effects. We now know that resecting the fundus is a key step in sleeve surgery irrespective of bougie size. Indeed, fundus resection is not only important for weight loss results but also to prevent postoperative acid reflux. Hiatal hernia repair dominated many discussions on acid reflux prevention following gastric sleeve surgery. The reality is that complete gastric fundus resection rather than hiatal hernia repair is the key to acid reflux control in the setting of sleeve gastrectomy.

“Association of radiographic morphology with early gastroesophageal reflux disease and satiety control after sleeve gastrectomy” by Moreno et al is a study published in the Journal of the American College of Surgeons in 2014. The study analyzes the gastric sleeve shape on routine post-operative gastrointestinal series. Those patients with retained fundus had lower satiety scores and higher severity of reflux symptoms. Along the same lines, Gagner el al published a series of 36 redo gastric sleeve surgeries in 2014 in Surgical Endoscopy journal. The indications for revision surgery were failure to loose weight, weight regain and intractable acid reflux. All patients had a large gastric fundus. The mean percentage of excess weight loss after sleeve revision was 58.5 % (±25.3) (p < 0.0004) for a mean follow-up of 20 months (range 6-56 months). Acid reflux related symptoms resolved in two patients after redo gastric sleeve.

Is gastric sleeve surgery the right choice for you? The answer is most likely yes granted that the gastric fundus is completely resected to give you the best weight loss possible and the least likelihood of developing acid reflux disease after surgery.

#### Is Keto Safe?
“Eat food, not too much, mostly plants”, Michael Pollan’s seven words to healthy eating represents the most reasonable nutrition advice we can give to patients. Plant-based diet is the healthiest, safest and most environmentally friendly diet to consume. Numerous studies have demonstrated the benefits of vegetarian diets in terms of reducing the risk of cancer, hypertension, stroke, heart disease... Adding a small amount of animal protein to a plant-based diet prevents vitamin deficiencies, improves food flavor, and nutrient content. As such the Mediterranean diet, my preferred diet, is one of the best diets to adopt. However, a plant-based diet, rich in carbohydrates is not ideal for individuals who suffer from obesity and diabetes. Unfortunately, the majority of the US population in general and Houstonians in particular suffer from either obesity or diabetes or both. An oatmeal breakfast with fruits like banana is a great energy source for a lean person; but for an overweight patient with insulin resistance such a breakfast is a big problem. In the setting of insulin resistance, a carbohydrate rich meal presents a huge burden for the body to process and metabolize. The end result of such burden is pancreatic islet cells failure with uncontrolled blood sugar requiring escalating doses of short and long acting insulin. When discussing the merits and safety of a diet, an individual metabolic state and the environment in which this particular individual lives, must be taken into consideration.

Is Keto safe for overweight and insulin resistance individuals? The short answer is that we don’t know yet. We don’t have long-term studies evaluating the long-term side effects of keto diet. We know from previous studies conducted on epileptic children maintained on high fat diet that ketosis results in increased risk of osteoporosis and kidney stones. Cardiologists in particular are naturally opposed to a high fat diet fearing the risk of increased cholesterol blood levels and heart disease. Some have suggested an increased risk of early death and cancer. There are however no good quality studies to confirm these claims. For keto advocates, a high fat diet is lifesaving. "Paleo, Atkins, Mediterranean diet... The struggle was real because I tried everything, and nothing really worked. I was thinking that food is my enemy, but with the KETO diet food is my medicine. I am more productive, full of energy all the time and the results are fascinating. Now I eat delicious foods without so many restrictions" said Reese Hutton. It is currently the only diet that bypasses the faulty carbohydrate processing mechanism especially in obese and insulin resistant patients, leading to significant weight loss. Bariatric surgery like gastric sleeve procedure, restores the Magenstrasse pathway of carbohydrate gastric emptying. A normal Magenstrasse emptying pathway initiates a cascade of gastro-intestinal neurohormonal secretion that allow proper carbohydrate digestion, absorption and metabolism. Keto diet, low in carbohydrates, does not require a functioning Magenstrasse emptying pathway. Keto diet results in a state of ketosis. Obese patients with insulin resistance can process ketone bodies without any hindrance. The end result is significant weight loss in the absence of starvation and feeling hungry all the time.

Of note, keto diet is easy to start but hard to maintain. Dietary discipline and commitment are needed to maintain the weight loss. Daily food tracking, regular exercise, and intermittent fasting will help keep you on track. Unlike bariatric surgery, there is no meal size restriction with keto diet. Eating too many calories, however, on a keto diet results in poor weight loss. One advantage of keto diet is the satiety level it induces. You don’t need to snack in between meals when you are in ketosis. Keto diet abolishes the ups and downs of blood glucose levels; hence, it eliminates hunger and associated food cravings especially when fasting. Intermittent fasting is an integral component of a successful keto diet for weight loss. There are many benefits for fasting besides weight loss that I will discuss in a future blog. Last but not least, leafy green vegetables like cabbage, broccoli, asparagus, spinach and peppers are an essential source of fiber, vitamins and antioxidants in any keto diet. Make a commitment to eat a whole food, not junk food, keto diet, with plenty of water to achieve the best possible result.

#### Is Mini Gastric Bypass a Safe Option for Weight Loss?
Mini-gastric bypass also known as single anastomosis gastric bypass surgery is a non-endorsed weight loss procedure by the American Society of Bariatric and Metabolic Surgery, ASMBS. Bile reflux and the risk of malignancy have been the main concern with mini gastric bypass when compared to the standard Roux-en-Y gastric bypass surgery. Billroth II reconstruction increases the risk of bile pooling in the remnant stomach which in turn may end up in the esophagus. I have performed a number of mini gastric bypass revision to Roux-en-Y gastric bypass for severe bile reflux and/or marginal ulceration and gastric pouch outlet stricture.

A number of studies from around the world have demonstrated the safety and efficacy of mini gastric bypass over the past few years. A recent study published in Surgery of Obesity and Related Disorders journal claims that mini gastric bypass and classic Billroth II reconstruction are two different animals. The authors of “Esophagogastric junction function and gastric pressure profile after minigastric bypass compared with Billroth II” show that classic Billroth II reconstruction is associated with lower esophageal sphincter pressure and lower gastric remnant pressure when compared to mini gastric bypass. Consequently, the authors find increased incidence of alkaline and acid reflux in the small study group of Billroth II patients.

The study has a number of significant limitations, but the authors are to be congratulated in attempting to understand the underlying physiology associated with each procedure. In the absence of a hiatal hernia, mini gastric bypass anatomy may protect against acid and bile reflux given the pressure differential between the stomach and intestines favoring rapid emptying. Additional studies are needed to further consolidate these observations. One thing for sure, the gastric resection in mini gastric bypass must be meticulously performed, as it is the case with sleeve gastrectomy, to accelerate gastric emptying. Accelerated gastric emptying promotes weight loss and protects against acid and bile reflux.

#### Is Mounjaro Exacerbating Your Food Regurgitation?
Jane from Houston sent us this question: “I am currently taking Mounjaro to help me lose weight. I lost 26 pounds so far. However, I am waking up at night with food regurgitation. I tried to sleep on my left side and elevate the head of my bed. I also avoid eating late at night before going to sleep. My heartburn is still controlled by Nexium but sometimes I feel nauseated. I also feel more bloated. What can I do?”. Thank you.
Dear Jane,
GLP-1 agonists like Mounjaro and the newly introduced Zepbound are commonly used now for treatment of obesity and type 2 diabetes. GLP-1, (glucagon like peptide-1), decreases appetite, increases satiety, and it slows down gastric emptying. The most common side effect of delayed gastric emptying is nausea. Around 20% of patient on Mounjaro and Zepbound experience nausea. Vomiting and abdominal pain occur in 10% of patients.
Furthermore, delayed gastric emptying increases bloating, intragastric pressure, food retention and stomach acid secretion. Consequently, if you have acid reflux disease, delayed gastric emptying may worsen your acid reflux symptoms. Acid reflux patients on Mounjaro are particularly prone to food regurgitation during sleep. Nocturnal acid reflux symptoms are quite disruptive. Your quality of sleep will suffer. This will negatively affect your mood and energy levels. Food regurgitation at night also increases the risk of aspiration and pulmonary problems.
Food regurgitation is poorly controlled with PPIs like Omeprazole and Nexium. Head of bed elevation and avoiding food intake within 3 hours of going to bed may help.
Surgical therapy in the form of a properly performed hiatal hernia repair and Nissen fundoplication is the most reliable treatment for food regurgitation. Once the acid reflux barrier is restored, you can safely resume Mounjaro. A second option to consider is hiatal hernia repair and weight loss surgery like sleeve gastrectomy. This approach is preferred when your BMI is more than 35. A properly performed sleeve gastrectomy and hiatal hernia repair can reliably alleviate acid reflux symptoms and at the same time help you lose weight without the need for GLP-1 agonist medications.

#### Is Pyloroplasty a Reasonable Solution for Gastroparesis?
Bill asked us this interesting question this week: Can you please provide me with more information about gastric resection for treatment of gastroparesis?

I have severe refractory gastroparesis. My GI doctor and surgeon want me to do a pyloroplasty despite no evidence of vagal nerve damage. My issue is slowed motility. I already have a G and J tube. I'm very interested in your work with gastric fundus resection. I would like to learn more. I have an aunt who lives in Houston. Thank you.

Dear Bill,

Your question is very smart, and your concern is quite appropriate. Why offer pyloroplasty for treatment of severe refractory gastroparesis when the real problem is gastric dysmotility rather than vagal nerve dysfunction and failure of pylorus muscle to relax? Gastric emptying is a highly coordinated process that doesn’t simply depend on gravity to evacuate gastric content through an open pylorus. By the same token, a gastro-jejunostomy that creates a wide connection between stomach and intestine to facilitate gastric emptying doesn’t work at all in severe gastroparesis.

Currently, there are no guidelines for treatment of severe refractory gastroparesis. Small studies published in the literature along with a general consensus among general and bariatric surgeons support either gastric bypass or pyloroplasty to treat refractory gastroparesis. The last article I reviewed for treatment of gastroparesis with gastric bypass surgery showed no symptom improvement. The study was published in Surgery for Obesity and Related Diseases journal.

Few years ago, a study showed that sleeve gastrectomy increased gastric emptying. It is thought that by resecting the stretchable part of the stomach along the greater curvature, gastric wall compliance decreases and stomach emptying increases. The mechanism of action may be more complicated since resecting the greater curvature also eliminates gastric pacemakers that play an important role in stomach motility.

Since there are no guidelines for treatment of gastroparesis and since current treatment options like gastric bypass and pyloroplasty make no sense to me, I applied the concept of sleeve gastrectomy to refractory gastroparesis cases and I had great success. I perform an antral preserving longitudinal gastrectomy. I preserve the antrum because it is the gastric pump and is a thick muscle with low wall compliance that promote gastric emptying. Most of the gastric fundus is resected. In cases of gastroparesis after Nissen fundoplication, I preserve the fundoplication and resect the greater curvature between the fundoplication and antrum. Unfortunately, my experience is limited to less than 10 cases, but the outcome of my approach has been great. All symptoms of gastroparesis completely and immediately resolved following surgery in all patients I operated on.

For these reasons, I am not a fan of pyloroplasty and I am completely opposed to offering gastric bypass for treatment of gastroparesis. Hopefully, future studies will help further delineate the best approach to management of refractory gastroparesis.

#### Is Sleeve Gastrectomy the Best Gastroplasty for Weight Loss?
Over the past 50 years a number of gastroplasties have been developed to treat obesity. From the first horizontal gastroplasty to the latest endoscopic sleeve gastrectomy, bariatric surgeons in Houston and all over the world attempted to reduce stomach volume in hopes of restricting food intake and promoting weight loss. Increasing satiety, however, and modulating the central regulatory mechanisms for weight loss are not simply the result of gastric volume reduction. As a result, most of these gastroplasties failed to achieve permanent weight loss and only one survived: Sleeve Gastrectomy. Sleeve gastrectomy is a metabolic procedure that in addition to mechanical restriction, it alters gastrointestinal hormone secretion that affect organs like the pancreas, liver and brain. The end result is decreased hunger and increased satiety. Unlike gastric plication and endoscopic sleeve gastrectomy (better called endoscopic gastric plication), sleeve gastrectomy increases gastric emptying. Increased gastric emptying is the one common mechanism of action to all successful metabolic procedures for weight loss like gastric bypass.
Magenstrasse or stomach road is a fast emptying pathway of gastric liquids from the postprandial stomach. Soluble ingested simple carbohydrates like fructose and sucrose dissolve in gastric liquid and are “dumped” into the duodenum to stimulate the secretion of a number of neuro-hormonal signals like GLP-1 and PYY. These neuroendocrine signals stimulate carbohydrate metabolism and control satiety and body weight. They play an important role in the pathophysiology of obesity and type-2 diabetes. A number of gastric procedures enhance the Magenstrasse emptying pathway including Nissen fundoplication, Magenstrasse and Mill gastroplasty also known as reversible gastric sleeve) and sleeve gastrectomy. All three procedures are associated with increased gastric emptying and increased GLP-1 and PYY.
Along those lines, I developed sleeve gastrotomy hoping to increase gastric emptying while preserving most of the stomach tissue for food digestion, acid production, vitamin absorption. Magenstrasse emptying pathway is generated by well-coordinated gastric fundus and antrum contractions. The aim behind sleeve gastrotomy is to potentiate these contractile waves to restore the Magenstrasse emptying pathway. If this theory can be proven, sleeve gastrotomy would be the best gastroplasty for weight loss.

#### Is Sleeve surgery a good option for patients with heartburn?
The incidence of heartburn in our overweight patient population is very high. Heartburn results when acid backs up into the esophagus. Normally, a competent lower esophageal sphincter, LES, acts as a barrier against acid reflux into the esophagus. With weight gain, fat accumulates inside the abdomen increasing the pressure on the stomach and leading to acid reflux. Furthermore, a higher intra-abdominal pressure increases the incidence of a hiatal hernia. A hiatal hernia occurs when part of the stomach herniates into the chest thereby leading to a weak LES. To make things worse, overweight individuals tend to overeat especially at dinnertime. Overeating stretches and weakens the LES, further aggravating the reflux of acid. Delayed gastric emptying and a dilated gastric fundus (upper part of the stomach) promote the development of a permanent “acid bubble” in close proximity to the LES which in turn may contribute to the increased incidence of acid reflux in this patient population.
At Houston Weight Loss Surgery Center, we offer the sleeve gastrectomy for most patients with a body mass index (BMI) higher than 35 and suffering from heartburn. Sleeve surgery allows for long-term effective weight loss leading to alleviation of most acid reflux symptoms. Sleeve gastrectomy is currently the most commonly performed weight loss procedure around the world. During sleeve surgery 85% of the stomach is resected ending up with a banana shaped stomach. As you loose weight following sleeve surgery, heartburn tends to resolve. A recent study published in the Annals of Surgery by Dr. Morino showed that heartburn resolves after sleeve gastrectomy in the majority of patients who suffered from gastro-esophageal reflux disease (GERD) prior to surgery. The study also showed that new onset acid reflux after sleeve gastrectomy is rare. Interestingly, the study demonstrated that sleeve surgery increases the pressure of the lower esophageal sphincter, LES, hence strengthening the acid reflux barrier. This is an additional anti-reflux property for the sleeve that is independent of weight loss.
At Houston Weight Loss Surgery Center, the only contraindication for sleeve surgery in GERD (gastro-esophageal reflux disease) patients is the presence of Barrett’s esophagus. Barrett’s esophagus results from long standing severe acid reflux and possible bile reflux into the lower esophagus. In this case, gastric bypass surgery is a better option for weight loss. Gastric bypass diverts acid and bile from the lower esophagus therefore preventing and halting the progression of Barrett’s into cancer. Gastric bypass also preserves the rest of the stomach in case it is needed in the future for reconstructive surgery if esophageal surgery is ever needed.
If you have persistent heartburn and interested in weight loss, Dr. Darido offers state of the art effective solutions for both heartburn and excess weight. Please give us a call at 281.205.3205 for a free private consultation at Houston weight loss surgery center.

#### Is Weight Loss Surgery a Good Option for Achalasia Patients?
Achalasia is a rare esophageal dysmotility disorder of unknown etiology. It is characterized by loss of esophageal peristalsis and failure of the lower esophageal sphincter to relax. Patients develop dysphagia to solids and liquids.

Traditionally, achalasia patients lose weight due to inability to eat regular food. Most end stage achalasia patients present in a malnourished and underweight state. These days, however, almost all achalasia patients referred to Houston Weight Loss Surgery Center are overweight or obese. Obese achalasia patients report gaining weight concomitantly with their dysphagia progression. Patients with difficulty swallowing, replace their regular diet with calorie dense liquids or soft food items. Fruits, vegetables, meats and complex carbohydrates gradually become harder and harder to swallow. Thus, achalasia patients limit their diet to sweets, ice cream and milkshakes… Such a high glycemic index diet is likely to contribute to gradual weight gain as achalasia progresses over time. Consequently, overweight patients who develop achalasia tend to be obese upon presentation for evaluation.

Heller myotomy with partial fundoplication is the traditional treatment for achalasia. For obese patients, however, adding a Roux-en-Y gastric bypass instead of fundoplication seems to be more advantageous for several reasons. Obese achalasia patients constitute 45% of our achalasia patients at Houston Weight Loss Surgery Center. The remaining patients are overweight. A weight loss procedure in the setting of a Heller myotomy offers the obese achalasia patient an opportunity to fix 3 problems at the same time: Obesity, GERD and Dysphagia. I prefer Roux-en-Y gastric bypass over gastric sleeve surgery following Heller myotomy for three reasons. First, gastric bypass surgery preserves the stomach as a potential conduit for future esophageal reconstruction in case esophagectomy is needed in the future. Achalasia patients are at higher risk for developing esophageal cancer and esophageal resection may be needed. Second, Roux-en-Y configuration of gastric bypass surgery is a negative pressure system that promotes esophageal food emptying. Gastric sleeve lumen pressure is typically elevated (at least per published studies) and may theoretically hamper esophageal emptying. Third, I have had great experience alleviating GERD related symptoms in Lap Band patients who developed pseudo-achalasia due to long-term band over-restriction. I have performed around 25 band to gastric bypass conversions in these situations with excellent results. Food regurgitation, heartburn and aspirations successfully resolved following gastric bypass surgery even in the setting of a massively dilated esophagus.

#### Is Your Gastric Sleeve Dilated?
Gastric sleeve surgery is a restrictive bariatric procedure. Stomach volume is greatly reduced resulting in small meal consumption. Weight loss, however, is not related to stomach volume reduction. Gastric sleeve induced weight loss is a physiologic result of altered gastrointestinal neuro-hormonal signals secondary to increased gastro-intestinal motility. These signals affect certain parts of the brain favoring weight loss. Gastric sleeve patients experience decreased appetite, and increased satiety with small meals. Carbohydrate digestion, absorption and metabolism improve leading to normalized blood sugar levels and weight loss. Gastric sleeve surgery patients who maintain a healthy lifestyle enjoy a lifelong weight reduction.
Patients who fail to adopt healthy eating habits tend to overeat and stretch the gastric sleeve lumen. Patient with a dilated gastric sleeve present to their bariatric surgeon with weight regain, increased appetite, and increased meal size. A contrast study typically reveals uniform dilation of the gastric sleeve lumen. Preferential dilation of gastric sleeve lumen at the fundus level indicates functional narrowing at the incisura angularis. In such cases, there is poor initial weight loss and increased incidence of acid reflux.
For patients with a uniform gastric sleeve dilation we start with lifestyle changes and education on healthy eating habits. If patients are compliant, we proceed with gastric re-sleeve or conversion to gastric bypass or duodenal switch. The more weight regain the patient has experienced the less likely the re-sleeve will succeed in weight loss. Patients who have regained all their excess weight loss and more are advised to proceed with sleeve conversion to gastric bypass or duodenal switch. Conversion of dilated gastric sleeve to duodenal switch has the highest success rate.
Patient with a dilated gastric fundus and narrowed incisura angularis are better served with conversion to gastric bypass. A narrowed incisura angularis is associated with severe GERD and gastric bypass is the only solution to alleviate GERD symptoms in this situation.

#### Is your lack of sleep causing weight gain?
Being overweight is the result of hormonal imbalances that disrupt the metabolic system. A disrupted metabolic system leads to poor dietary choices, fatigue, increased appetite and low fat burning capacity. Sleep plays a pivotal role in regulating metabolism.
Ghrelin and leptin are two hormones that control appetite and energy metabolism. Sleep deprivation can cause a 19% decrease in the level of leptin and 28% increase in the level of ghrelin. The net result is increased appetite and decreased metabolic rate. Lack of sleep can also increase emotional eating for comfort rather than caloric need.
Insulin is another hormone that affects metabolism. In a study published in the Annals of internal medicine, researchers showed that after four nights of sleep restriction, insulin sensitivity was decreased by 30 percent. Decreased insulin sensitivity also called Insulin resistance leads to type-two diabetes and obesity. Indeed a study that followed about 70.000 women for 16 years, showed a significant increase in body weight in those who slept 5 hours or less compared to those who slept 7–8 hours.
Today we sleep on average 6.5 hours compared to 8.5 hours in the 1950s. As sleep time decreased over time there has been an increase in the prevalence of obesity. At Houston Weight Loss Surgery Center, we recommend you to improve our sleep hygiene to prevent weight gain. Here are a few tips:

Keep a consistent sleep schedule. Get up at the same time every day even on weekends and vacations. Go to bed early enough to have at least seven hours of sleep.
Avoid any caffeine in the afternoon. Caffeine will keep you in the lighter stages of sleep, which are associated with poor sleep.
Make your bedroom quiet and relaxing. Keep the room at a comfortable temperature and limit light exposure in the evenings.
Exercise regularly to improve sleep quality.
Watch what you eat before bedtime. Rich heavy meals before bedtime decrease the quality of your sleep. Avoid consuming alcohol before bedtime for the same reason.
Last but not least, if you snore at night, wake up with a headache or feel sleepy throughout the day, you may be suffering from sleep apnea. Sleep apnea is the sudden cessation of breathing during sleep. Obstructive sleep apnea results from sudden obstruction of the airway. Obstructive Sleep apnea is very common in overweight individuals. It can lead to serious health conditions if left untreated. There are different treatment solutions for obstructive sleep apnea. The most effective treatment for obstructive sleep apnea in overweight people is weight loss. At Houston Weight Loss Surgery Center, we offer outpatient testing for sleep apnea. Our patients have major improvement in sleep apnea following weight loss surgery.

In conclusion, good healthy sleep reduces your risk of weight gain. Adopting healthy sleeping habits is an integral part of a healthy lifestyle. If you are overweight you may want to adopt an effective weight loss strategy to improve your health and sleep. Houston Weight Loss Surgery Center offers effective and durable weight loss solutions.

#### Is your lap band causing you heartburn?
Adjustable gastric banding or lap band surgery is a weight loss procedure that is rarely performed nowadays. Few years ago, however, lap band surgery was quite common. The concept of adjustable gastric banding revolves around creating stomach restriction forcing the patient to eat less. The band is progressively tightened around the stomach by injecting fluid inside its lumen. Unfortunately, most patients were over-restricted in hopeless attempts to make them loose weight. Over-restriction resulted in near obstruction of the esophagus. Food passage into the stomach was hindered. Patients developed heartburn, food regurgitation, nocturnal cough, and vomiting.
If you have a lap band and suffer from heartburn, food regurgitation, nocturnal cough or vomiting you may be over-restricted. Band over-restriction if left unattended leads to irreversible damage to your esophagus. You may develop esophageal dilation and difficulty swallowing. The esophageal lining may herniate through its muscular wall creating a blind pouch we call diverticulum. Food accumulates in the diverticulum causing pain, regurgitation and nocturnal cough. Nocturnal cough results from food material backing up into your upper airway and lungs when you lay on your back. This is a dangerous condition as it puts at risk for aspiration pneumonia. Aspiration pneumonia is lung infection developing from stomach content entering your lungs.
If you have a lap band you need to follow up with your doctor on a regular basis for adjustments. If your band is causing you heartburn, and you are satisfied with your weight loss, Houston weight loss surgery center offers effective weight loss solutions. Dr. Darido will discuss with the best options to alleviate your symptoms and help you loose weight.

#### JAMA Obesity Theme Issue: Gastric Sleeve Surgery Is Here to Stay
The Journal of the American Medical Association, JAMA, current issue is entirely devoted to the medical problem of obesity. I was particularly interested by two published randomized studies comparing gastric sleeve to gastric bypass surgery with a 5-year follow-up. The Swiss Multicenter Bypass or Sleeve Study, SM-BOSS, and the Finnish Sleeve vs Bypass, SLEEEPASS, study showed similar weight loss and type 2 diabetes remission rate at 5 years. Reoperation rate was similar to both gastric sleeve and bypass patients in both studies. Repeat surgery was mainly for GERD in gastric sleeve patients and internal hernia for gastric bypass patients.

These two trials are landmark studies for gastric sleeve surgery establishing sleeve gastrectomy as a reliable, durable and safe weight loss procedure equivalent to gastric bypass surgery. Gastric sleeve surgery does not require intestinal mobilization and resection. Consequently, gastric sleeve, unlike gastric bypass, is not associated with long-term side effects like marginal ulcers and internal hernias. From a patient and surgeon perspective, the absence of long-term side effects is quite appealing. GERD, however, remains a concern with gastric sleeve surgery and both trials, currently published in JAMA, reported higher GERD incidence with sleeve gastrectomy compared to gastric bypass surgery. Our approach, however, at Houston Weight Loss Surgery Center and Houston Heartburn and Reflux Center, has effectively resolved this issue. Indeed, we offer sleeve surgery for overweight GERD patients as an alternative to the traditional Nissen fundoplication.

Gastric sleeve surgery, unlike Lap Band, has established itself as an effective and safe metabolic procedure for weight loss. Gastric sleeve, when properly performed, is associated with very low short-term and long-term complication rate. The only potential contender for gastric sleeve surgery is gastric fundus invagination. Gastric fundus invagination mimics the effects of gastric sleeve surgery without the need to resect gastric tissue and leaving a long staple line. Gastric fundus invagination modulates gastric function and interaction with food, leading to increased gastric emptying, while preserving most of the stomach. Gastric fundus invagination is a reversible, reproducible and simple procedure to perform.

#### Jimmy’s Success Story Could be Yours in 2017
Jimmy is a 50-year-old male who has been struggling with excess weight for the past 25 years of his life. 15 years ago, he underwent a purely restrictive procedure called Molina band in Houston, TX. Through an open approach, the weight loss surgeon at the time, placed a Gore-Tex band around the upper stomach creating a small gastric pouch with a narrow opening. The mechanical restriction allowed Jimmy to lose some of his excess weight. However, within few years and as it is expected with purely restrictive procedures he gained back around 100 pounds. Furthermore, he developed significant narrowing of the gastric pouch opening leading to gradual worsening of acid reflux, food regurgitation, inability to tolerate solid diet and daily vomiting. Over the past 10 years, Jimmy has been living on a puree diet including ice cream.

When Jimmy presented to my office, it was obvious that he had gastric pouch outlet obstruction. He underwent an upper endoscopy that confirmed the diagnosis and was immediately scheduled for revision surgery. The procedure we agreed upon was conversion of Molina band to Roux-en-Y gastric bypass. Jimmy underwent the surgery with no complications and had an uneventful recovery in a very short period. His heartburn and food regurgitation have resolved. His diet choices include now fruits, vegetables and lean proteins. He felt more energetic and was started to exercise daily. Jimmy likes weight lifting and one year after surgery he lost 110 pounds while building an impressive body physique.

Jimmy is the perfect example of a star bariatric patient. He used the gastric bypass procedure as a tool to overcome excess weight, sleep apnea, acid reflux and hypertension. He followed Houston Weight Loss Surgery Center recommendations and adopted a healthy lifestyle that allowed him to achieve the goals he has always wanted: live a healthy, happy and disease free life. If you or someone you know is interested in losing their excess weight and gain back their health give us a call. Our team of weight loss experts are happy to assist you.

#### Lap Band and Esophageal Damage
Emily from Pasadena sent us this question: “Had lap band removed in Nov 2019. Having esophagus trouble.  Food and drink sticking.  Food still there in the morning, wheezing and coughing at night. Constant heartburn etc…”

Dear Emily,

Lap band for weight loss causes significant damage to esophagus especially when over-restricted. Many bariatric surgeons fell in the trap of over-restriction in hopeless attempts at promoting weight loss. The end result of lap band over-restriction was damage to esophagus, and dissatisfied bariatric patients. Lap band damages esophageal motility resulting in a condition called pseudo-achalasia. Pseudo-achalasia patients have a dilated esophagus secondary to chronic partial obstruction created by lap band. Heartburn, difficulty swallowing, food regurgitation, cough and wheezing (especially at night) are some of the symptoms associated with band over-restriction and pseudo-achalasia. Aspiration pneumonia is a serious side effect of lap band over-restriction.

The first step in lap band over-restriction management is fluid removal. The earlier fluid is removed the less is esophageal damage. Patients who present after years of over-restriction require lap band removal. Most patients will slowly improve, and acid reflux symptoms resolve. Some may develop irreversible esophageal function loss resulting in persistent symptoms of acid and food regurgitation. In this case, first line of treatment consists of diverting gastric content from esophagus by performing a Roux-en-Y gastric bypass. Gastric bypass is quite an effective solution for acid reflux. Dysphagia, however, may not resolve. In these rare cases and especially in the setting of recurrent aspiration episodes esophageal resection is necessary. Fortunately, Lap Band is rarely performed these days in Houston. Our understanding of weight loss surgery mechanism of action has greatly evolved. We no longer think that mechanical restriction leads to weight loss. Rather, we know that bariatric surgery modifies a number of neuro-hormonal signals that alter satiety and metabolism leading to long-term weight loss.

#### Lap Band Long-term Outcome: A New Study from Switzerland
A well conducted study by a group of Swiss surgeons was recently published in Surgery for Obesity and Related Diseases (SOARD). A total of 405 Lap Band patients were retrospectively analyzed using prospectively collected data. The follow up rate was 85% and ranged from 8 to 18 years. One hundred patients exceeded 15-year follow-up.

The authors found that the majority of patients lost their band due to band intolerance defined or band slippage. Band intolerance occurred when patients developed reflux, dysphagia, food intolerance and abdominal pain not improving with band adjustment. Around 30% of evaluated patients maintained their bands and 15% of 334 patients had good to excellent weight loss outcomes.

The authors conclude that adjustable gastric banding should no longer be offered to obese patients. The evidence they present is the last nail in the Lap Band coffin. This is an important study with excellent long-term follow up rate. A restrictive device applied on the stomach to force patients to eat less and result in durable weight loss is a naïve assumption. Obstructing or restricting esophageal outflow can only result in complications like heartburn, food regurgitation, esophageal dysmotility and dilation. I have managed a number of Lap Band cases with significant esophageal dysmotility requiring complicated surgical repair and conversion to gastric bypass to remedy the condition.

Lap Band surgery, a procedure that had been rapidly and irrationally adopted, has failed as a bariatric and metabolic procedure. It is time for the FDA to withhold the device from the market. ASMBS has yet to publish a clear statement on Lap Band complications and ineffectiveness as a weight loss procedure. The evidence is overwhelmingly strong against Lap Band usage. I don’t see any indication for Lap Band use in our fight against obesity.

#### Lap Band Mechanism of Action and The Vagus Nerve
I read with great astonishment the newly published article in this month issue of SOARD titled “An investigation of the neural mechanisms underlying the efficacy of the adjustable gastric band”. The authors attempt to find an alternative mechanism of action besides mechanical restriction for the Lap Band. They rightly admit that restriction by itself does not lead to durable weight loss. Neuro-hormonal changes are the underlying mechanism for weight loss after gastric bypass and gastric sleeve surgery. Indeed, changes in Ghrelin, GLP-1 and PYY are the hallmark for successful metabolic procedures. However, no such changes have ever been demonstrated with adjustable gastric banding. This is most likely why Lap Band, as a weight loss procedure, has failed. Consequently, Lap Band has been reduced to a purely restrictive procedure, and rightly so, with poor long-term weight loss results. The assumption that filling the band with saline in order to “ optimize” restriction to controls hunger and promote weight loss has failed the test of time. This absurd assumption remains a painful reminder of how ignorant we were and how deficient our knowledge about obesity was just few years ago. Thousands of Lap Band patients have failed to loose weight. Many suffered from band related complications like erosion, slippage, esophageal dysmotility and dilation, acid reflux, aspiration pneumonia… in hopeless attempts to beat obesity and regain their healthy lives. This large-scale human trial, however, is still not enough for some Lap Band proponents and the company that manufactures Lap Bands.

In a rather desperate attempt, the authors of this article devise an elaborate weight loss trial in a rodent model. The authors assume that stretch receptors in the small gastric pouch above the inflated Lap Band are activated and send neural signals via the vagus nerve to the brainstem to promote satiety and weight loss. By denervating the afferent vagal nerve fibers using capsaicin, in a rat model, the authors showed abolished Lap Band induced weight loss.

I am a huge proponent of studying mechanisms of action of bariatric surgery. The neural component of metabolic surgery is still a black box. The gastro-intestinal system communicates with the central nervous system in a variety of ways. The vagus nerve is logically one of these communication pathways relaying thousands from the gut to the brain. However, we don’t understand these signals. Therefore, we don’t know how to manipulate these signals to promote weight loss and satiety. Assuming that stretch receptors in the gastric pouch above the inflated band, control satiety is quite naïve. I should mention that the pouch created by the band is not gastric in nature but rather esophageal. The only sure consequence of esophageal constriction is esophageal dysmotility and dilation.

One interesting observation we have learned from the large-scale, worldwide, lap Band human trial is that a minority of band patients does lose weight and maintain it for the long run. Those lucky patients require very little band adjustment. One or two band fills at most. They report increased satiety, small meal consumption without any nausea, vomiting, heartburn or discomfort. These patients are definitely worth studying, in my opinion, to figure out Lap Band mechanism of action. Do these patients have a decrease in fasting Ghrelin? Is their postprandial GLP-1 higher? Is their gastric fundus smaller in size than what we typically see in overweight patients? Is the gastric fundus excessively imbricated over the band?

Going back to a rodent model with all its deficiencies to demonstrate a failed weight loss concept doesn’t make lot of sense to me.

#### Lap Band, Achalasia, and Severe Esophagitis
The first case of the week for 2017, is a 43-year-old female who underwent lap band placement in 2013 by an outside institution. She presented to my office with epigastric pain, heartburn, food regurgitation and nocturnal cough. Her band was adjusted up to 5 cc in during the initial first few month after surgery. It was completely emptied for obstructive symptoms. The patient continued however to have several GERD related symptoms including dysphagia. She was started on high dose proton pump inhibitors by her bariatric surgeon but her symptoms did not resolve. Following office consultation, I learned that the patient had dysphagia related symptoms prior to lap band placement.

I made the decision to start with an upper endoscopy and a contrast study to evaluate the distal esophagus, rule out band erosion, and check for a hiatal hernia.

The patient had evidence of severe distal esophagitis. Several linear ulcers covered with fibrinous exudates were found extending up to cm above the Z line. The hiatal opening was dilated and the gastric pouch above the band was quite enlarged. There was no evidence of band erosion. An esophagogram showed a very large gastric pouch with no band slippage. Contrast emptying from the esophagus into the stomach was significantly delayed suggestive of weak esophageal contractions. Interestingly, she had significant narrowing at the level of the gastro-esophageal junction where the lower esophageal sphincter is located independent of narrowing at the lap band level. The bird’s beak picture was suggestive of achalasia.

Esophageal manometry was performed and confirmed the diagnosis of type 1 achalasia. The combination of absent esophageal motility and tight lap band has led to severe acid reflux and esophagitis, as well as dysphagia. The dilated gastric pouch secreted enough acid that freely refluxed into the esophagus across the dilated hiatal opening. Due to esophageal dysmotility, mucosal acid exposure was significantly prolonged leading to ulceration. The patient was started on Carafate and instructed to continue PPI treatment. The band will be first removed hoping to decrease the esophageal inflammation prior to performing a Heller myotomy with Toupet fundoplication. Gastric bypass with Heller myotomy is also a valid option especially if the BMI is above 35. This patient has lost a total of 45 pounds since her initial lap Band surgery and is not interested in gastric bypass surgery at this point.

#### Laparoscopic Treatment of Gastroparesis: A Single Center Experience
A new study on gastroparesis treatment was recently accepted for publication in SOARD (Surgery for Obesity and related Disorders) journal. The study is a retrospective, single center, evaluation of 15 vs 73 patients who underwent gastric bypass vs gastric electric pacing surgery for treatment of medically refractory gastroparesis. The authors attempt to analyze the effectiveness of each procedure by studying post-operative symptom improvement and anti-emetic medication use. The results indicate nausea resolution but no improvement in vomiting and pain and no reduction in medication use following gastric bypass. Gastric electric pacing improved nausea, vomiting and abdominal discomfort but medication use did not change. Such finding suggests that symptoms did not really improve following gastric pacing and patients continued to require pro-kinetic and anti-emetic medications.

These results are in accordance with previously published literature. Randomized, prospective controlled GES showed no improvement in gastroparesis patients. RYGB is not well studied for gastroparesis treatment. In my personal experience, I have seen no improvement of gastroparesis symptoms following RYGB especially in severe and medically refractory cases. A longitudinal gastrectomy, on the other hand, that preserves the gastric antrum has been quite effective for gastroparesis treatment. I have had great success in my private practice treating around 10 patients with severe gastroparesis. All gastroparesis related symptoms completely resolved immediately following surgery with no readmission over more than one year follow up.

Gastroparesis incidence is rising and we still don’t have a good understanding of its pathophysiology. Most importantly, there is no established effective treatment guidelines for gastroparesis. Many gastroparesis patients are left untreated or poorly treated with symptoms that significantly diminish their quality of life and overall health. A multidisciplinary and serious effort is needed to study this disease to establish a treatment protocol. Studies like the one currently published in SOARD clearly show the ineffectiveness of gastric pacing and gastric bypass surgery for treatment of gastroparesis. The authors, however, seem hesitating confirming this observation and rather conclude that both procedure offer some degree of symptomatic improvement. Some degree of improvement is simply not enough when it comes to gastroparesis treatment.

#### Late Onset GERD after Sleeve Gastrectomy
Rhonda from Pasadena sent us this question: “I had the gastric sleeve in Tijuana Mexico Feb 2015.  All was good the first couple years.  Since then I have had heartburn that is getting progressively worse.  I have been prescribed 40MG Pantoprazole twice /day. My question: Is gastric bypass the only solution for curing this acid reflux?”

Dear Rhonda,

Late onset acid reflux, many years after sleeve gastrectomy, is indicative of either recurrent hiatal hernia or new hiatal hernia formation. Recurrent hiatal hernia may develop secondary to weight regain or incomplete esophageal mobilization during initial repair. De novo hiatal hernia following sleeve gastrectomy may result from functional narrowing of gastric sleeve lumen. Functional narrowing occurs when the incisura angularis, the junction between lower one third and upper two thirds of the stomach is narrowed during gastric sleeve surgery. It is a fairly common mistake when bariatric surgeons use a very small size bougie during sleeve gastrectomy.

Functional narrowing of incisura angularis alters gastric emptying pattern and promotes backflow of gastric content towards the esophagus. Initially, in the setting of a competent acid reflux barrier, you will not have acid reflux. With time, the anti-reflux barrier fails, and acid reflux develops. This result in several acid reflux related symptoms like heartburn and food regurgitation. Acid reflux is a major cause of hiatal hernia development. Consequently, a hiatal hernia slowly develops leading to gradual gastric sleeve migration into the chest. When part of the gastric sleeve lumen is in the chest, bile reflux in addition to acid reflux develop and GERD symptoms worsen to the point that high dose PPIs no longer control symptoms.

The treatment for acid reflux after sleeve gastrectomy entails hiatal hernia repair with or without gastric bypass. In the absence of gastric sleeve narrowing, hiatal hernia repair is more than enough to restore the anti-reflux barrier and control acid reflux. If, however, the gastric sleeve is narrowed, conversion to gastric bypass is needed in addition to hiatal hernia repair.

#### Let Food Be Thy Medicine: Bone Broth
Bone Broth is made with bones. Typically chicken or beef bones are roasted then simmered in excess of 24 hours. A splash of vinegar is added to the simmering water to help extract minerals from bones. A variety of spices (black pepper, cumin, cinnamon…) and herbs are added to suit your taste. At the end of cooking, bones should crumble when gently pressed. An eight-ounce cup of bone broth delivers nine grams of proteins, plenty of minerals like calcium and magnesium and just 40 calories. This nutrient dense liquid is different from the watered down, store bought, boxed and canned broth. These commercially prepared broths are highly processed and lack the flavor and nutritious value of home made bone broth.
I strongly recommend bone broth to my patients before and after surgery. Prior to surgery, bone broth will replenish your mineral deficiencies, restore your immune system, build up your protein stores, heal the lining of your intestines and prepare your metabolism for surgery. After surgery, homemade bone broth is the perfect drink to recover. For bariatric patients, I recommend adding one scoop of Unjury chicken flavor protein powder to a warm cup of homemade chicken broth. This is the best full liquid diet meal you can consume especially in the first 2 weeks after gastric sleeve or bypass. Patients typically prepare their broth prior to surgery and store the liquid in small containers in the freezer for daily use after surgery. You can buy Unjury protein powder online at www.unjury.com or at Houston Weight Loss Surgery Center.

#### Long-Term Outcomes of Lap Band Surgery: The Big Lesson
Fabrizio Vinzens et al have recently published a study titled “Long-term outcome of laparoscopic adjustable gastric banding (LAGB): Results of a Swiss single-center study of 405 patients with up to 18 years follow-up”. The follow up rate was 85%. Follow up duration ranged from 8 to 18 years after Lap Band placement with one hundred patients exceeding 15 years in follow up. During this long-term follow-up 71% of adjustable gastric bands were removed. Most these patients were converted to sleeve gastrectomy, Roux-en-Y gastric bypass or duodenal switch. 29% this patient cohort still has their band in place and half of them report good to excellent outcome. Overall, 15% of the total patient population has benefited from Lap band surgery.

In my opinion, this is the best published long-term study on adjustable gastric band surgery outcome. The authors have clearly and objectively demonstrated, over an impressive mean follow up of 13 years, that lap band surgery is not an effective and durable weight loss procedure. Most importantly, the study reinforces the now established concept of metabolic surgery: mechanical restriction by itself, a naïve assumption adopted by many bariatric surgery pioneers, is not an effective weight loss solution. Yet, the FDA continues to approve weight loss procedures like gastric balloon. Other innovators in the field, are still experimenting with various endoscopic techniques of gastric volume reduction like endoscopic gastroplasty. A few bariatric surgeons still perform gastric pouch and stoma reduction procedures for gastric bypass patients. Sadly, numerous publications of successful outcomes of such non-sense procedures continue to be published in SOARD and other bariatric journals. There was a devoted session at Obesity week this year in New Orleans about new techniques in bariatric surgery. All techniques centered around gastric volume reduction and all outcomes were described as excellent and promising. Lap band surgery results in the smallest possible gastric pouch and yet it has failed to achieve any durable weight loss for most obese patients. I think this study has clearly demonstrated the futility of restrictive weight loss procedures.
It is time we learn our lessons and move forward with a new vision based on facts and a clearer understanding of metabolic surgery. Research and funds in the fields of energy metabolism, nutrition and obesity must be streamlined and centered on one important concept: Stomach volume reduction resulting in calorie reduction and starvation is not an effective weight loss solution. Once we accept this established concept, we can focus our efforts at understanding bariatric surgery mechanism of action. This will allow us to develop new less invasive and more effective solutions. It may help us develop drugs for obesity treatment. Most importantly, knowledge and evidence based medicine will allow us to test a novel weight loss procedure prior to its approval and widespread application. For instance, if increased gastric emptying is a mechanism of action of a weight loss surgery then endoscopic sleeve gastroplasty that delays gastric emptying cannot be approved for weight loss. Many patients will be spared the disappointment and frustration of a failed bariatric procedure like the current study has shown with Lap band surgery.

#### Manga Gastrica en Houston | Gastric Sleeve in Houston
Excess weight leads to many problems that shorten longevity and decrease quality of life. Obesity causes high blood pressure, diabetes, fatty liver, sleep apnea, depression, acid reflux and arthritis. Weight loss surgery and in particular sleeve gastrectomy (Manga gastrica en espanol) is effective, and safe treatment for excess weight. Sleeve gastrectomy is an outpatient, minimally invasive procedure. Surgery is performed through tiny incisions resulting in very little post-operative pain and fast recovery.
At Houston Weight loss Surgery Center, gastric sleeve surgery is the most offered weight loss procedure. Our comprehensive approach to weight loss management and our attention to detail result in high success rate. Our patients do not develop acid reflux after sleeve gastrectomy. We pay special attention to hiatal hernia repair during sleeve surgery to prevent acid reflux from developing after gastric sleeve procedure.
If you struggle with excess weight and obesity related complications like fatty liver and diabetes, give us a call at 832-945-8717. Our bilingual and experienced nurses, bariatric nutritionists, and patient coordinators will help you through your weight loss journey.

#### Meatless Diet In Houston, TX
I am not a vegetarian and I do enjoy a nice juicy steak from time to time. I love red meat because it is delicious and quite satisfying to eat. However, I am conscious about my health including my blood cholesterol level, my blood pressure, my weight, my heart… I make sure to take care of my body to preserve it and be able to do the things I like to do. Your health is your best wealth and knowledge is power. Understanding that excessive red meat consumption on a daily basis can damage your health will save you a lot. Tomorrow is the rodeo kick off and I am invited to several BBQ events. In preparation, I went vegetarian all day. I had fava beans for breakfast, dandelion, roasted beets and avocado salad for lunch and lentil soup for dinner. And believe me these are tasty dishes that I enjoy eating anytime of the week. The idea that vegetarian meals are boring and tasteless is not true. Quite the contrary, if you invest in learning how to prepare vegetables, beans, and grain based dishes you won’t be disappointed. There is more to plant based dishes than cold salads. These dishes are light, easy to digest, reflux friendly, cholesterol free, and rich in minerals, antioxidants and complex carbohydrates. A combination of beans and grains can provide you with all the proteins you need on a daily basis without the dangers of red meat. The world health organization (WHO), has recently declared that red and processed meat are directly related to cancer. A plant-based diet can save your life. You can still enjoy your burger or steak from time to time but don’t make it a habit of having eggs and bacon for breakfast, a burger for lunch and a steak for dinner. This is more than your body can handle and you will end up suffering from hypertension, obesity, hypercholesterolemia, obesity and cancer. Explore different cuisines and keep your mind open. Indian, Mexican and my favorite Lebanese cuisines have been perfected over thousands of years. Traditional Lebanese dishes are amazingly diverse, delicious, and easy to prepare. The variety of ingredients and the balanced meals you can prepare yourself in a short amount of time will not disappoint your taste buds.

I don’t want to spoil your Rodeo fun tomorrow. Remember that Rodeo food is OK to enjoy from time to time but don’t make it a habit. Fried rich food is a burden on your digestive system and your whole body in general. Choose light, fresh, green and plant based as the bulk of your daily diet. From Houston Weight Loss Surgery Center we wish all Houstonians a great Rodeo time.

#### Modern Economics Has Given Us Abundance and Obesity
I read with great interest the book review published this week in the wall street journal. The Economists’ Diet: The Surprising Formula for Losing Weight and Keeping It Off is the book title written by two economists: Chris Payne and Rob Barnett. Both Chris and Rob suffered from obesity and managed to lose a combined weight of 120 pounds. They did not follow a particular diet or exercise program but rather applied what they know best: economic principles to build healthy habits and keep the weight off.

Modern day economics has increased our income, but also our portion size and waistlines resulting in a classic case of market failure: Unbounded demand has met almost unlimited supply. The food industry responded to our voracious appetite for sweet, salt and fat with bigger, juicier, sweeter, and saltier processed food items. The abundance of cheap, calorie dense food in the setting of a largely sedentary lifestyle has fueled the obesity epidemic.

The Economists’ diet plan presents a “behavioral” austerity program to fight abundance and keep weight under control. The authors recommend rethinking the traditional 3 square meals a day. They typically consume a light breakfast and lunch allowing for a larger evening meal to enjoy with family. In order to reinforce the austerity plan, the authors recommend weighing yourself daily. Daily weight is a powerful behavioral reminder to avoid snacking in between meals when hunger or boredom kicks in. Payne and Barnett continue to advise us to be calorie conscious as opposed to the tedious and impractical calorie counter. They recommend eating boringly and have the same salad and protein over and over to build a habit. New culinary experiences stimulate eating, even in the absence of hunger, leading to weight gain. Still, the authors maintain that life without the occasional splurge or feast is a life less well lived. You need, however, to learn how to budget your diet: For every feast there need to be a fast. When you have a large lunch, we learn to skip the next meal to balance your daily caloric intake.

This book will be published on January the second of 2018 and I look forward to reading it. Payne and Barnett offer practical tips to limit calorie intake and prevent weight gain in an obesogenic environment. However, obesity as a disease is much more complicated than a simple calorie in and calorie out equation. There is no doubt that chronic overeating is a major cause of obesity and preventing such a habit and lifestyle is highly recommended. Weighing yourself frequently and actively working on maintaining your weight by increased physical activity and decreased food intake is also recommended. The problem, however, is when we are already 50 or 100-pound overweight such preventative tactics no longer work. Obese patients have a metabolic problem and skipping meals can only exacerbate the disease. Starvation at this point, does not reverse the underlying neuro-hormonal imbalance. The authors warn us that adopting their strategy for weight loss is challenging. It takes at least 18 months to lose significant weight and a lifetime of restrained behavior after that to keep it off. Indeed, the bigger you are the more difficult it is to achieve durable weight loss using such an approach.

Today, bariatric surgery, also known as metabolic surgery, is the most effective solution for significant and durable weight loss. Bariatric and metabolic procedures like gastric sleeve surgery allows patients to eat less and at the same time, feel full and satiated. In the absence of hunger, and appetite control it is quite hard to maintain the austerity program, Chris Payne and Rob Barnett are advocating in their book. Prevention, however, remains better than treatment. If you are overweight, follow the Economists’ Diet for 2018 and put an end to weight gain. If you are obese, BMI more than 35, give Houston Weight Loss Surgery Center a call, and reclaim your health.

#### Modified Gastric Sleeve Surgery for Treatment of Gastroparesis
I am sharing a letter I received from a patient overseas to shed light on a prevalent yet poorly understood disease that significantly affects the quality of life of millions of people around the world. Hundreds of patients in Houston suffer from gastroparesis or delayed gastric emptying. There are no effective medications that promote gastric emptying. Severe gastroparesis like this case is particularly debilitating and hard to live with.

“Dear Dr. Elias Darido,
I would appreciate it if you could kindly give me an opinion on my wife’s severe gastroparesis. On April the 7th 2016 she underwent hiatoplasty and Nissen fundoplication surgery for reducing her hiatal hernia. Unfortunately, after this surgery she suddenly had a severe gastroparesis (evidenced by an X-ray scan with gastrografin as a contrast medium). For almost two months – non continuatively – she has been treated with the following drugs: Ursodesossicolic acid (UDCA) 450 mg (1/die); Domperidone (2/die) Butyric acid (colonlife) (1+1/die) And eating a semi-liquid diet No improvement was achieved. In June she started to take: resolor prucalopride 2 mg (1/die), for two weeks, and at the same time erythromycin 1000 mg x2 die, for one week. Still no improvement was achieved. In July she was still feeling pain and so she could not eat, if not after a digestive process taking three days to complete. She experienced significant weight loss: from the 68 kg she weighed in April before the surgery, she now was 55 kg in July. (Height 168 cm; 49 years old) After several consultations by many doctors, the 12th of July 2016 she has been treated with a laparascopic surgery consisting of: Gastric-resection and Roux-en-Y anastomosis; However, after six days due, to surgery complications she underwent a further “laparascopic explorative surgery + adhesiolysis” She then progressively started to eat a liquid diet, a semi liquid diet, taking resolor prucalopride 1 mg (2/die) and erythromycin 500 mg (2/die) but nothing worked, the remaining 50% of her stomach is very dilated and eventually she had to stop eating, still having a severe gastroparesis. Since the 5th of August she had been only fed through parenteral nutricion. Nothing has changed, but even worse! She weighs 50 Kilos now. … I thank You very much for the attention and for the time you have dedicated to read this letter.”

Medically refractory gastroparesis patients often resort to surgery. There is however no consensus in the surgical community on what procedure to use for treatment of severe gastroparesis. Some advocate a pyloroplasty especially in the setting of a Nissen fundoplication. Others support the use of gastric bypass surgery as a mean of allowing food to bypass the paralyzed stomach. Personally, I don’t think that simple gastric drainage like a pyloroplasty or gastro-jejunostomy is a good treatment for gastroparesis. Similarly, Roux-en-Y gastric bypass surgery does not address the underlying problem. The dilated gastric remnant continues to cause the same symptoms of pain, bloating and inability to tolerate regular diet. Historically a subtotal gastrectomy has been performed for refractory gastroparesis. The procedure is quite invasive and is associated with poor outcomes and decreased survival. The lesson I learned from reviewing the literature and studying these cases is that resecting or bypassing the stomach is not a good solution for gastroparesis. Rather, partial gastric resection mainly involving the gastric fundus and greater curvature results in improved gastric emptying and symptom resolution in all 6 cases I have so far performed.

I call the procedure I have developed for treatment of gastroparesis modified gastric sleeve surgery or a longitudinal gastric resection. I perform a greater curvature resection including most of the gastric fundus while preserving the antrum. The antrum is the gastric pump and does not seem to contribute to gastroparesis. I have applied this technique on 6 patients so far with great success. Two of those patients have developed gastroparesis following Nissen fundoplication. Historically, gastroparesis following fundoplication surgery has been attributed to vagal nerve injury. I think, however, that these patients had an underlying element of gastroparesis contributing to acid reflux. Possible vagal nerve injury has most likely worsened the underlying gastroparesis issue.

I have been taken care of a young man with severe gastroparesis for the past one year. He had a Nisen fundoplication 6 years ago for presumed GERD. A year ago, he underwent revision surgery for presumed twisted wrap. His Nissen fundoplication was converted to a Toupet. He has continued however to have the same epigastric pain and bloating and presented to my office for a second opinion. I ordered a gastric emptying study that confirmed gastroparesis. An upper endoscopy showed large amount of solid food residue in the stomach. I tried a number of prokinetic medications with no success in alleviating his symptoms. Finally, I offered him the modified sleeve gastrectomy. The stomach was resected along the greater curvature starting at the junction between the antrum and gastric body. The Toupet fundoplication was left intact and most of the gastric body was resected while preserving the antrum. Patient symptoms improved readily after surgery and a post-operative contrast study showed accelerated contrast emptying from the stomach into the duodenum. It has been 3 months now and he continues to do very well.

The modified gastric sleeve procedure for treatment of gastroparesis deserves to be thoroughly evaluated as a potential cure for gastroparesis. There has been very little progress made in our understanding of gastroparesis and gastrointestinal motility disorders in general. Obesity, type 2 diabetes and gastroesophageal reflux disease are closely associated with gastrointestinal motility malfunction. It is time for the medical community to start investing time, energy and money in figuring out these motility disorders and their impact on very common diseases that have reached epidemic level in our society.

#### Morbid Obesity, GERD, Gastroparesis and Type 2 Diabetes: What Do They Have in Common?
Surgical manipulation of the gastric fundus by resection, plication, invagination or bypass results in physiologic changes. These changes have immediate and significant therapeutic effect leading to improvement and sometimes cure of chronic progressive diseases like obesity, GERD, gastroparesis and type 2 diabetes. Indeed, the most effective and most reliable treatment for morbid obesity and type 2 diabetes is gastric fundus resection in the form of sleeve gastrectomy, or gastric fundus bypass in the form of Roux-en-Y gastric bypass surgery. Similarly, the best treatment for acid reflux disease is a 360 or 270-degree fundoplication. As for gastroparesis, I have had great success performing a longitudinal gastrectomy that preserves the gastric antrum and resects most of the gastric fundus to promote gastric emptying.

The oldest surgery performed on the gastric fundus to alter a pathophysiologic process was the Nissen fundoplication. Dr Nissen came across his procedure by serendipity more than 50 years ago. It is thought that wrapping the gastric fundus around the lower esophagus, reinforces the lower esophageal sphincter leading to acid reflux control. However, we know now that acid reflux disease is a multifactorial problem and the exact mechanism of Nissen fundoplication is not well understood. Rather than increasing the resting lower esophageal sphincter pressure, Nissen fundoplication alters gastric motility and emptying patterns favoring cephalad movement of gastric content away from the gastro-esophageal junction. A short and floppy fundoplication that avoids constricting the lower esophageal sphincter is currently the accepted surgical standard. The purpose of fundoplication surgery is to reconfigure the gastric fundus anatomy and wall compliance rather than reinforce the lower esophageal sphincter. Similarly, gastric fundus resection in sleeve gastrectomy results in increased gastric emptying and altered gastro-intestinal neuro-hormonal signaling. Such physiologic changes are more important than mechanical restriction to achieve significant and durable weight loss as well as type 2 diabetes remission. Few years ago, I published a case report about a type 2 diabetes patient with severe and medically refractory gastroparesis. The patient had been constantly vomiting and had lost significant amount of weight. He was TPN dependent to meet his calorie needs and replace his electrolytes. His stomach and duodenum were dilated. I performed a longitudinal gastrectomy that preserved the antrum. Due to his malnutrition, I elected to preserve some of the gastric fundus and body. I also performed a side to side duodeno-jejunostomy to decompress the dilated duodenum. Patient’s gastroparesis related symptoms immediately resolved and tolerated liquid diet on day one after surgery. His diet was rapidly advanced to regular food and 4 years following surgery the patient remains asymptomatic. Interestingly, the patient type 2 diabetes of 15 years resolved and his blood sugar normalized as he was regaining all his lost weight. The case clearly illustrated the relationship between gastric fundus surgery and gastric emptying and their effect on type 2 diabetes remission.

Gastric fundus anatomy and physiology plays a crucial role in the pathophysiology of many diseases that have reached an epidemic level in our society. Gastric fundus surgery alters gastro-intestinal motility patterns leading to improvement and most often remission of obesity, GERD, type 2 diabetes and gastroparesis.

Reference:
Laparoscopic longitudinal gastrectomy and duodenojejunostomy for treatment of diabetic gastroparesis. Surg Obes Relat Dis. 2012 Nov-Dec;8(6):811-3.
Darido E, Farrell TM.

#### Mounjaro Is Not Helping Me Lose Weight
Jennifer from Houston sent us this question: “I’ve been on GLP1… but I don’t lose a pound unless I do Keto. Is my Mounjaro dosage not enough? I’m 5’ 5” tall and 215 pounds. Are my satiety hormones that bad that the leading weight loss drug can’t even help me? You’re a bariatric surgeon, so you’re going to probably tell me to have a gastric sleeve surgery. But what about GLP1 and the keto? I’m hoping when I lose my excess weight, I no longer must do keto. And I can lower my dosage of GLP1 when I am at maintenance for life. Is this an actual possibility?
Dear Jennifer,
Mounjaro, a GLP-1 agonist, is an effective medication for weight loss. GLP-1agonists control appetite and increase satiety. They also increase insulin sensitivity. Consequently, your daily caloric intake decreases, and your carbohydrate metabolism improves. This results in significant weight loss in most patients. However, up to 15% of patients do not respond to GLP-1 therapy despite increasing the dosage.
If you are not losing weight on GLP-1agonist therapy, bariatric surgery remains the most effective weight loss solution. Sleeve gastrectomy is both safe and reliable. Sleeve gastrectomy mechanism of action relies on increasing your own intestine secretion of GLP-1 and numerous other neuro-hormones that increase satiety and decrease appetite. Sleeve gastrectomy is indeed more effective than GLP-1 agonist injections.
Please remember that healthy eating is always recommended whether you are on GLP-1 treatment, or you have undergone sleeve gastrectomy. A healthy eating regimen is not necessarily a keto regimen. At Houston Weight Loss Surgery Center, we recommend a nutritious diet regimen based on lean protein, legumes, nuts and fresh vegetables and fruits.

#### Mounjaro or Endosleeve for Weight Loss?
Mounjaro or Tirzepatide is an injectable prescription medication that consists of both glucose dependent insulinotropic peptide (GIP) and Glucagon-like peptide-1 (GLP-1) receptor agonists. GLP-1 and GIP are hormones secreted by stomach and intestines in response to food intake. GLP-1 and GIP decrease hunger, increase satiety, reduce insulin resistance, and promote weight loss. GLP_1 is one of several hundred hormones that plays a central role in weight loss following sleeve gastrectomy.

Endoscopic sleeve gastroplasty or Endosleeve, on the other hand, is a biologically inert procedure. Endosleeve does not alter stomach and intestine hormone secretion following meal intake. Endoscopic sleeve gastroplasty is a mechanically restrictive weight loss procedure like Lap Band. By reducing stomach, endoscopic sleeve gastroplasty forces overweight patients to eat less without altering the neuro-hormonal response to food intake. Consequently, Endosleeve patients reports constant hunger and increased appetite resulting in limited weight loss.

On the other hand, overweight patients on a once weekly injection of Mounjaro, have decreased appetite and hunger levels, and increased satiety and metabolism. Mounjaro, unlike Endosleeve, decreases your food intake without putting you in a starvation mode. This is crucial to achieve long-term and reliable weight loss. If you are looking into a non-surgical weight loss option, GLP_1 agonists are currently a much better option for you than endoscopic sleeve gastroplasty.

#### New Year, New Resolution: Take control of Your Appetite
Year after year, 70% of all Houstonians who struggle with excess weight pledge to eat less, exercise more and lose weight. Hunger control is, however, crucial to successful weight loss. Gastric sleeve surgery patients report increased satiety with very small meals. Patients on low calorie diet, on the other hand, feel hungry most of the time. The constant feeling of hunger is hard to fight and as a result most Houstonians fail to achieve durable weight loss. Within a month from the start of the new year, all dieting efforts are dropped, and the weight loss cycle repeats itself every year.
The best approach to increasing satiety and decreasing hunger for durable weight loss hinges on understanding obesity and its underlying pathophysiology. Obesity is a state of starvation. The neuro-hormonal imbalance associated with obesity channels most ingested calories to fat cells leaving the rest of the body including the brain calorie deficient. A calorie deficient brain leaves us hungry and craving for calorie rich food items. A low-calorie diet, in such a situation, exacerbates the starvation state and increase hunger level. One of the key signals in the neuro-hormonal imbalance leading to fat cell calorie accumulation is insulin. Without insulin fat cells cannot hoard calories and accumulate fat. Carbohydrates and in particular processed carbohydrates like white bread, white rice, and sugary drinks increase insulin secretion and lead to increased hunger levels and fat accumulation. Accordingly, the first step to weight loss and hunger control relies on decreasing insulin blood levels. This implies stopping carbohydrate intake including fruits, grains, starch rich tubers and all forms of processed food rich in high fructose corn syrup.
There are many books, publications and seminars supporting decreased carbohydrate intake to lose weight. Keto diet is the extreme form of a low carbohydrate diet approach to weight loss. Keto diet relies on fat as the primary source of energy.  It forces the body to go into ketosis to help mobilize fat deposits and promote weight loss. Most importantly, patients on keto diet have increased satiety levels allowing them to reduce their overall calorie intake hence resulting in durable weight loss.
For 2019, Houston Weight Loss Surgery Center invites you to better understand obesity and weight loss methods. We are here to help you overcome any weight loss hurdle you may encounter so that you can start enjoying your life again. If you have any questions give us a call today.

#### Nissen-Sleeve operation, is it an option?
David Nocca, MD, head of Bariatric Surgery department at the University of Montpellier in France is currently conducting an international bariatric workshop about a new weight loss procedure: Nissen-Sleeve operation. The French team have already published a pilot study in SOARD in 2016 demonstrating Nissen-sleeve surgery feasibility and safety in 25 patients. The authors advocate that this approach eliminates acid reflux following gastric sleeve surgery with comparable weight loss outcomes to the traditional sleeve gastrectomy. A secondary advantage of Nissen-sleeve surgery is a decrease in the risk of staple line leak at the angle of His. The authors further advocate that the risk of remnant gastric fundus ischemia in Nissen-sleeve surgery is low given the rich blood supply of the stomach.

I personally believe that a wrapped fundus is metabolically and functionally equivalent to a resected gastric fundus. In other words, A properly performed Sleeve gastrectomy is not associated with increased risk of acid reflux. In fact, I use gastric sleeve surgery to treat GERD in obese patients. Acid reflux develops or worsens following gastric sleeve surgery when the incisura angularis is narrowed, hiatal hernia is not repaired, gastric fundus is incompletely resected and gastric antrum is resected. When gastric sleeve surgery was first introduced, bariatric surgeons aggressively resected the stomach over very small bougie size. Bariatric surgeons assumed that the smaller gastric sleeve volume is the better is weight loss. These unproven assumptions mutilated the stomach and resulted in narrow high pressure gastric tubes: A recipe for acid reflux.

Gastric sleeve surgery like any successful metabolic procedure is not simply a restrictive procedure. The antrum or gastric pump should be preserved to promote gastric emptying. The incisura angularis diameter cannot be narrowed over a 32 F bougie to prevent gastric content backflow into the esophagus. The gastric sleeve cannot be exposed to negative intra-thoracic pressure as this will favor not only acid reflux but also bile reflux. Therefore, any size hiatal hernias must be repaired to prevent GERD in the setting of sleeve gastrectomy.

Accordingly, I don’t see a major role for Nissen-sleeve surgery as a primary weight loss procedure. However, in a revision scenario, Nissen-sleeve surgery can be quite useful. I have personally used the Nissen-sleeve approach in obese patients with history of Nissen fundoplication. Rather than taking down the fundoplication and resecting the gastric fundus, the wrap was preserved, and a longitudinal gastrectomy was performed between the antrum and lower part of the fundoplication. I have also performed a Toupet or 270-degree fundoplication in patients who had incomplete gastric sleeve surgery with a large retained gastric fundus and severe acid reflux. This scenario is especially common in patients who undergo lap band to sleeve revision in one setting. Lap band creates excessive scarring around the gastro-esophageal junction preventing proper dissection and sleeve resection when attempted at the same time as band removal. Typically, patients have an associated hiatal hernia, esophageal dysmotility and an incompetent lower esophageal sphincter secondary to Lap Band over-restriction. All 3 factors lead to severe GERD in the setting of morbid obesity. I typically repair the hiatal hernia and use the remaining gastric fundus to perform a partial wrap. The few cases I did had excellent acid reflux control following surgery.

In short, a properly performed gastric sleeve resection is an excellent anti-reflux procedure. Standardizing proper sleeve gastrectomy technique and increasing awareness about acid reflux management and hiatal hernia repair are better options than developing a hybrid new procedure to treat two common disorders like GERD and Obesity.

#### Not All Calories Are Created Equal
I read with great interest the article “ Isocaloric fructose restriction and metabolic improvement in children with obesity and metabolic syndrome” by Robert Lustig, MD. This unique study was recently published in Obesity journal. The experimental trial included 43 obese children who were placed on a low sugar diet for 9 days. The 9-day diet matched the number of daily calories the participants consumed prior to the study. The only difference was that sugar was reduced from 28% to 10% and substituted for starch. Chicken teriyaki was replaced with turkey hot dogs. Bagels substituted for pastries… The quality of the diet itself did not change. Children continued to consume a processed food kind of diet but with less sugar. The purpose of the study is to isolate the effect of sugar on health independent of weight gain or calories ingested. The children weighed themselves daily, and if they were losing weight, they were told to eat more of the provided food in order to keep their weight the same throughout the study.

At 10 days, there was a significant decrease in mean arterial and diastolic blood pressure, a decrease in fasting glucose and insulin resistance and a significant drop in VLDL and LDL. These results are impressive. Robert Lustig has clearly demonstrated that not all calories are created equal, and sugar is toxic. Sugar independently of weight gain or calorie intake can wreak havoc on your metabolism leading to a myriad of chronic diseases like obesity, diabetes, hypertension, and hypercholesterolemia…

At Houston Weight Loss Surgery Center, we insist on eliminating sugar, in all its forms, from our patient’s diet. There is no other way around it. We know it is difficult because sugar is as addictive as drug of abuse like cocaine. Sugar is present in most food items you buy of the shelf in American grocery stores. Indeed, patients at Houston Weight Loss Surgery center have one important skill to learn and maintain before and after bariatric surgery: Home cooking. Whether you are undergoing a gastric sleeve or gastric bypass unless you prepare most of your food at home you will have difficulty maintaining weight loss and improving you health. No one adds sugar to a homemade dish of baked chicken or oven roasted veggies. The food industry has to add sugar to processed food in order to preserve the item, improve its taste and make it more addictive.

Take home message: Let food be thy medicine. What you put in your mouth will either make you healthier or sicker. It is your choice. Take control of your diet and eating habits. Drop the sugars and look for alternatives in nature made complex carbohydrates like whole grains, and root vegetables like Parsnips, sweet potatoes, and carrots…Check you local grocery store or farmers market for in season produce. Follow our Facebook page for weekly recipes and call us for any dietary question that concerns you.

 

#### Obesity and GERD: Weight loss surgery options
GERD remains an intriguing disease with several important unanswered questions about its rising incidence, precipitating factors, underlying pathophysiology and relationship to the obesity epidemic. Today, around one-third of all Americans experience a GERD-related symptom at least once weekly.
Esophageal adenocarcinoma, a complication of GERD, is the fastest-rising cancer in the U.S. Abdominal girth and excess weight contribute to GERD. Several studies demonstrate a strong, almost linear association between BMI and GERD. Obesity may promote the development of GERD. If true, what would be the underlying mechanism?
The link between obesity and GERD seems to be related to increased intra-abdominal pressure secondary to abdominal fat accumulation. Intra-gastric pressure increases, promoting a backflow of gastric content into the esophagus. Several studies have shown that GERD patients’ increasing BMI is independently associated with increased intra-gastric pressure. While logical, these findings are a simplistic interpretation of a complex problem.
GERD is a result of a weak LES
GERD pathogenesis is centered on the gastroesophageal junction (GEJ). This complex and dynamic structure is comprised of the lower esophageal sphincter — the surrounding crural diaphragm — the angle of Hiss (angle where the intra-abdominal esophagus joins the stomach) — and the phrenoesophageal membrane (PEM). The diaphragmatic crura prevent strain-induced reflux events, while the angle of Hiss configuration prevents increased gastric pressure-induced reflux events. The PEM is composed of elastin intertwined with thick bundles of collagen. Elastin contributes to its elasticity and flexibility, while collagen confers strength. This delicate balance between flexibility and strength allows the remaining components of the GEJ to work in synchrony and with clocklike precision: relaxing, contracting and contorting to gastric pressure variations with upward esophageal movements to prevent reflux. Secondary to obesity, a persistent elevated intra-abdominal pressure may challenge the delicate PEM (the Achilles heel of the anti-reflux barrier). A weak and lax PEM causes anatomic changes in the structure of the GEJ that evolve into functional failure of multiple acid reflux defense mechanisms like low sphincter pressure, transient lower esophageal sphincter relaxation, prolonged acid clearance, and changes in the post-prandial acid pocket position. The end result is the development of an overt hiatal hernia: the only independent predictor for GERD.
Weight loss surgery options rather than acid suppression
Interestingly, increased gastric acid secretion is not a contributing factor in the GERD pathogenesis — quite a paradox in that acid suppression has been the mainstay of GERD therapy for the past 50 years. Particularly in the obese patient population, GERD treatment should mainly rely on weight loss rather than acid suppressive therapy. The most effective weight loss therapy for obese patients is bariatric surgery. Roux-en-Y gastric bypass surgery is an established anti-reflux procedure. It diverts the acid-producing stomach away from the esophagus. The literature remains ambivalent on the effect of sleeve gastrectomy in resolving acid reflux disease. Is gastric fundus resection during sleeve gastrectomy equivalent to gastric fundus plication during a Nissen fundoplication surgery? A recent prospective study by Morino et al. showed resolution of symptomatic GERD following sleeve gastrectomy in morbidly obese patients. Will the sleeve gastrectomy have a role in GERD treatment in obese patients?
Additional studies are needed to answer these questions. As GERD continues to rise, new screening, diagnostic and treatment paradigms will emerge.

#### Obesity in America
The American Society for Metabolic and Bariatric Surgery (ASMBS) funded a survey of 1509 adults representing the US household population. The survey was completed in 2016 and aimed at evaluating public perception of obesity.

The results show that Americans consider obesity as a disease with serious health consequences like heart disease and diabetes. Interestingly, women and persons with higher level of education are more likely to consider obesity as a multifactorial problem as opposed to a lifestyle choice. While the majority believes that something must be done to prevent obesity, older individuals, lower education level, and republicans think that it is up to the individual rather than the healthcare system to prevent obesity.

The survey further shows that most Americans favor diet and exercise as a safe and effective weight loss solution. The majority of surveyed individuals are unsure about the effectiveness and safety of weight loss surgery. 68% believe that living with obesity is riskier than having weight loss surgery. 25% of obese individuals have considered weight loss surgery and women were 3 times likely than men to have considered weight loss surgery. Among those who have considered surgery for weight loss, and did not proceed with surgery, financial cost was the main impediment.

The American public perceives obesity as a health risk factor. Yet, most Americans are still confused about the nature, causes and available treatment options for obesity. The majority battle obesity using diet and exercise without consulting with a healthcare professional. In the eye of the public, obesity remains a lifestyle issue rather than a disease.

At Houston Weight Loss Surgery Center, we stress the crucial point and basic fact that while diet and exercise are essential at preventing obesity, they are ineffective treatment options for obesity. In other words, adopting a healthy lifestyle, eating a clean and light diet, and exercising on a regular basis are effective means to ward off obesity. Once obesity sets in, however, it is hard to shed the extra weight without reversing the underlying metabolic abnormality. Today, sleeve gastrectomy and gastric bypass surgery are the most effective and safest tools to reverse the pathophysiology of obesity. Following weight loss surgery, adopting a healthy lifestyle is crucial to maintaining weight loss. Without weight loss surgery, calorie restriction and starvation by themselves are less likely to lead to permanent weight loss.

#### Obesity, Metabolism and the Circadian Rhythm
The Nobel prize in medicine and physiology has been awarded this year to three American scientists for discovering the underlying molecular mechanism of biological clocks. Biological clocks allow us to follow a circadian rhythm that allows numerous body functions to synchronize to the light-dark cycle on earth. Biological clocks control our sleep pattern, as well as metabolism, energy expenditure, and body weight. A mismatch between these internal clocks and our lifestyle or external environment results in disease and lack of well being. Experiments in mice showed that altering feeding time from dark to light phase results in weight gain. Furthermore, mice fed a high fat diet ad libitum develop obesity. Mice fed the same diet over an 8-hour period only restricted to the dark phase did not gain weight. In addition, genetically engineered mice that lack the circadian clock in adipocytes tend to consume more calories during the light phase and develop obesity. Interestingly, the overall calorie intake does not change in these mice. These experiments show that a temporal change in feeding disrupts energy balance resulting in obesity.

When you eat may be as important as what you eat. More than 90% of our patients at Houston weight Loss Surgery Center skip breakfast. Patients who skip breakfast graze on food throughout the night because of decreased satiety and increased hunger. Studies in humans have shown that overweight individuals lose more weight when consuming most of their calories in the morning. Furthermore, fasting glucose and blood triglyceride levels tend to decrease by consuming a big breakfast and a small dinner without changing the total daily calorie intake. Indeed, we recommend to our patients to avoid carbohydrate consumption at dinner time as it serves no other purpose than fat accumulation. Conversely, a breakfast rich in complex carbohydrates provides excellent hunger control throughout the day and increased satiety around dinner time.

There is strong evidence that link circadian rhythms and energy metabolism. Every organ in the body has a biological clock that works synchronous with the master clock in the brain. Future research will unravel more details about this delicate and complex rhythmic physiology. Living in synchrony with these internal clocks optimizes your metabolism and may help you lose excess weight or prevent obesity from developing.

#### One Stage Gastric Band Removal and Conversion to Gastric Sleeve
Several studies have shown that a two-stage conversion of lap band to gastric sleeve is safer than a single stage approach. In the current issue of Surgery for Obesity and Related Diseases, a group of bariatric surgeons from Saudi Arabia demonstrate that a single stage approach is safe and effective. The study is based on a single-surgeon prospective database and included 209 band to sleeve conversions. Only one patient of the 209 conversions developed a staple line leak.

The lead author reports that key to avoiding complications in one stage band to sleeve revisions is meticulous and complete dissection of the fibrous capsule surrounding the stomach at the band site. The capsulotomy is started at the level of the left crus muscle and extended anteriorly to release any tethered gastric wall and fully mobilize the gastric pouch above the band. The author further recommends that the gastric pouch that is often dilated must be completely resected to avoid leaving behind a high-pressure area that may lead to increased leak rate.

This photo illustrates the technique described whereby the fibrous capsule is dissected prior to stapling.



At Houston Weight Loss Surgery Center, we advocate a two-stage band to sleeve revision. Most published studies have shown increased leak rate following revision bariatric surgery in general and the one stage band to sleeve conversion. This is due to several theoretical factors like scar tissue formation, decreased blood supply, dilated and inflamed gastric tissue above the band as well as increased gastric pouch pressure and esophageal dysmotility. Pseudo-achalasia secondary to gastric banding is not uncommon. Revising a lap band to a high-pressure system like gastric sleeve may increase the intra-luminal pressure at the gastro-esophageal junction especially in pseudo-achalasia cases. This may potentially contribute to increased staple line leak rate. Interestingly, one stage lap band to gastric bypass revision is not associated with increased leak rate. This may be due to the negative pressure system created by the Roux-en-Y configuration. At Houston Weight Loss Surgery center, we routinely offer a one stage band to gastric bypass revision.

To summarize, scar tissue dissection and removal is a must. However, removing the fibrous capsule by itself is unlikely to decrease the sleeve leak rate as other factors are at play. I do agree with the author that the capsule must be removed completely to release the gastric wall and prevent stapling part of the capsule. We have adopted this approach several times and had no leak. However, I do not consider the one stage approach to be a standard of care. It is not superior to the two-stage revision. I prefer for the inflammation and fibrosis to heal and gastric tissue as well as esophageal function to recover over a 6-month period prior to gastric sleeve resection. If the patient insists on a one stage approach for insurance or financial reasons we offer lap band to gastric bypass revision as the safest and most effective solution.

#### Optimizing Weight Loss After Sleeve Gastrectomy
Weight loss after sleeve gastrectomy varies from patient to patient. Many factors contribute to this variation. Accelerated gastric emptying after sleeve gastrectomy is one of those contributing factors that greatly affect the degree of weight loss after bariatric surgery.

Indeed, one of the most important mechanisms of actions of sleeve gastrectomy in terms of weight loss is stimulating gut hormone secretion. Gut hormones like GLP-1 (Glucagon like peptide), is secreted by intestines in response to food emptying from stomach. GLP-1, commercially synthesized and sold under the name of Ozempic, Mounjaro… curbs appetite leading to decreased food intake and weight loss.

It is well known that dumping or accelerated gastric emptying stimulates gut hormone secretion. Therefore, gastric sleeve surgery that best accelerates gastric emptying is associated with best weight loss outcome.

An interesting publication titled “Delayed gastric emptying after sleeve gastrectomy is associated with poor weight loss” was published in 2022 in Obesity surgery journal. The authors demonstrated a strong correlation between poor weight loss following sleeve gastrectomy and gastric emptying rate. They showed a pattern of meal retention in the proximal sleeve lumen in most patients with poor weight loss after sleeve gastrectomy. This is most likely due to narrowing of incisura angularis (the natural stomach angulation between its horizontal and vertical parts), a common mistake among bariatric surgeons. Narrowing of the incisura angularis secondary to aggressive stomach resection over a small bougie size leads to neo-fundus formation. Neo-fundus is the dilation of the proximal gastric sleeve lumen due to functional narrowing of sleeve lumen most commonly at the incisura angularis. From a weight loss mechanistic point of view, this finding is quite significant. It basically shows that bariatric surgeons who aggressively resect the stomach to achieve the best weight loss, end up with the poorest weight loss outcomes. For the mechanism of action of sleeve gastrectomy does not rely on mechanical restriction secondary to stomach volume reduction. Rather, physiological changes in gut neuro-hormone signaling secondary to accelerated food emptying from stomach into intestines lead to weight loss after sleeve gastrectomy.

From this perspective, the best weight loss after sleeve gastrectomy is achieved by resecting the stomach in a way that best accelerates gastric emptying. Consequently, avoiding a narrowed incisura angularis is strongly recommended during sleeve surgery to achieve best weight loss. At Houston Weight loss Surgery Center, we have adopted this approach since 2014. Not only did we achieve great weight loss results in our sleeve gastrectomy patient population, but we have also achieved a 0% rate of post-sleeve gastrectomy staple line leak and acid reflux. Indeed, by avoiding a narrowed incisura angularis, the risk of staple line leak at the upper part of the sleeve lumen goes down to zero. The risk of post-op GERD also greatly diminishes with this approach. At Houston Weight Loss Surgery Center, pre-operative acid reflux and hiatal hernia are not contraindication for sleeve gastrectomy. Our data clearly show resolution of GERD following a properly performed hiatal hernia repair and sleeve gastrectomy. A sleeve gastrectomy that does not narrow the incisura angularis, thus leading to accelerated gastric emptying.

#### Orbera vs Ozempic for Weight Loss
Ozempic, Wegovy, Saxenda…are injectable prescription medications that mimic the effects of Glucagon-like peptide-1 also known as GLP-1. GLP-1 is a gut hormone secreted by the intestines in response to food intake. It promotes weight loss, increases satiety, and stimulates insulin secretion while blocking glucagon release to decrease blood sugar. Both Sleeve gastrectomy and gastric bypass procedures increase GLP-1 secretion. GLP-1 has been strongly suspected as a key mediator in metabolic surgery especially when it comes to the immediate post-operative diabetes resolution.

Extensive research by pharmaceutical companies has led to the development of GLP_1 agonist like Ozempic, Wegovy and Saxenda. These medications were initially developed, and FDA approved for type 2 Diabetes treatment. However, Ozempic, Wegovy and Saxenda result in significant weight loss, and they are currently prescribed for overweight patients. These medications are safe and easy to use. They are also cheaper and much more effective than intra-gastric balloon placement for weight loss.

Weight loss gastric balloons like Orbera, force you (not help you) to eat less. These are mechanically restrictive procedures that have no effect on your satiety, metabolism, and insulin resistance. Purely restrictive weight loss procedures like gastric balloons, endoscopic sleeve gastroplasty and Lap band surgery do not alter gut hormone secretion. Gastric balloon patients are hungry, starving, and craving food. On the other hand, an overweight individual, on once weekly injection of Ozempic, has decreased appetite and hunger levels, and increased satiety and metabolism. Key to successful weight loss is decreasing food intake without feeling hungry. Medications like Ozempic, unlike gastric balloon, can decrease your food intake without putting you in a starvation mode.

If you are looking into a non-surgical weight loss option, GLP_1 agonists are currently a better option for you than gastric balloon placement.

#### Overeating doesn’t make you fat. The Process of Getting Fat Makes You Overeat
Always Hungry? Conquer Cravings, Retrain Your Fat Cells, and Lose Weight Permanently is a recently published book by David Ludwig. The author is a professor of nutrition at the Harvard T.H. Chan School of Public Health. The book reaffirms what metabolic and weight loss surgery research has demonstrated several years ago. Obesity is not simply the result of excess calorie consumption. It is rather the direct consequence of a change in hormones that control body weight, energy metabolism and appetite. The end result is a vicious cycle of cravings, hunger, and binge eating that results in excess weight accumulation. Cutting down on calorie intake by itself does not result in durable weight loss. The underlying cause of obesity, i.e. the hormonal imbalance, MUST be addressed first in any weight loss treatment model.
Ludwig explains that obesity is a state of starvation rather than a state of excess. The fat cells are engorged with calories but the brain has no access to these stores due to high insulin levels. As a result, the brain sends signals to eat more placing the overweight individual in a never-ending cycle of overeating and weight gain. From this perspective, it is easy to understand that cutting down on calories to lose weight, in the setting of the above mentioned hormonal imbalance, can only result in more hunger, more eating and more weight gain. Thousands of individuals in the greater Houston area who attempt to lose weight every year are all too familiar with this experience. Eat less and move more is in fact a futile approach to lose weight when the metabolic machinery of your body is malfunctioning.
What causes this hormonal imbalance? According to Ludwig, the low fat, very high carbohydrate food that we have been eating for the last 40 years, raises insulin levels and promotes fat accumulation. The obesity epidemic we suffer from today is the result of our modern processed food diet culture. Accordingly, he recommends getting rid of processed carbohydrates to lose weight. His program for weight loss starts with two weeks free of simple sugars and grain products as well as any form of processed carbohydrate like fructose corn syrup. Patients are allowed to consume non-starchy vegetables, fruits and beans. Whole grains are slowly reintroduced. All meals are based on whole natural foods with high quality meat and fat products. A diet high in good fats found in nuts, olive oil, avocados, fish… is highly recommended by Ludwig as it lowers insulin levels and calms chronic inflammation of rapidly expanding fat cells. This is the first step in jump-starting your metabolism to start weight loss.
The value of this book lies in its approach at debunking the myth of eat less and move more to lose weight. Weight loss is difficult to achieve without addressing the underlying hormonal abnormality. As a weight loss and metabolic surgeon, I think that good quality nutrition is important for durable weight loss. However, the most effective approach to reducing insulin levels in the body remains metabolic surgery like gastric sleeve and gastric bypass. For most obese individuals, the damage to gut and fat cells is too advanced. Retraining fat and gut cells is best achieved with weight loss surgery. Weight loss surgery, contrary to previous assumption, is a hormone altering procedure. I wouldn’t be opposed however to start all obese patients with a diet program as proposed by Dr. Ludwig and monitor response. Those who fail to achieve the desired weight loss will be offered metabolic and bariatric surgery like gastric sleeve. Those who lose their excess weight will be spared surgery. In either case, adopting a wholesome and natural diet free of processed carbohydrates remains crucial to maintain weight loss for the long run.

#### Overweight and Suffering from Heartburn? We Can Help.
Heartburn and food regurgitation are difficult to control when you are overweight. The constant pressure over the stomach forces gastric juices to escape into the esophagus. Large meals consumed daily and especially at night stress the gastro-esophageal junction area and promote acid reflux. A large and dilated gastric fundus contributes to frequent transient lower esophageal sphincter relaxation episodes leading to increased gastric content reflux into the esophagus. If you are overweight and you suffer from acid reflux disease or GERD, Houston Weight Loss Surgery Center and Houston Heartburn and Reflux Center have a solution for you. As a specialist in both acid reflux disease and weight loss surgery, I have developed a unique protocol to address GERD in overweight individuals living in Houston and surrounding communities.

There is a strong relationship between GERD and obesity. One cannot address GERD while ignoring obesity and vice versa. Weight loss, healthy food choices, and small meals serve both the overweight and heartburn patient.

Nissen fundoplication and gastric bypass surgery have traditionally been the most reliable treatments for GERD. Nissen fundoplication creates an effective antacid barrier with excellent long-term results. Gastric bypass is equally effective with the added benefit of weight loss in the overweight patient. A properly constructed gastric sleeve (no narrowing at the incisura and no retained gastric fundus) effectively diverts gastric content and acid away from the esophagus. Both gastric sleeve and gastric bypass are great solutions for GERD and obesity. Patients who are more than 50 pounds overweight and who suffer from multiple obesity related comorbidities like type 2 diabetes should strongly consider weight loss surgery over Nissen fundoplication for treatment of GERD. Nissen procedure is associated with some weight loss but not enough when compared to gastric sleeve surgery or gastric bypass procedure. Neumayer et al published a study in 2005 in Surgical Endoscopy showing significant weight loss after Nissen fundoplication. He showed persistent weight loss of around 9 pounds at one year after Nissen procedure in a group of patients with an average starting BMI of 27.6. Our experience at Houston Heartburn and Reflux Center, does not support such finding. We have noticed that the majority of our Nissen fundoplication patient, average BMI around 30, gain all their weight back at one year after surgery.

Proper hiatal hernia repair and complete circumferential distal esophageal dissection are crucial for the success of sleeve gastrectomy as an anti-reflux procedure. Hiatal hernia repair may be challenging in the obese patient. Indeed, it is almost impossible to properly release the distal esophagus in the setting of an enlarged liver and thick abdominal wall. For this reason, we put all our overweight patients on a 2-to-3-week of protein shake diet to shrink liver size. Shrinking liver size prior to surgery increases our access to hiatal hernia and distal esophagus to allow for proper dissection and repair.

Another component for success of sleeve gastrectomy as an anti-reflux procedure is good esophageal function. GERD patients presenting for weight loss surgery, mainly sleeve gastrectomy, undergo esophageal manometry. Manometry allows to measure lower esophagus sphincter pressure and esophagus contractions. Poor esophageal motility and decreased lower esophagus pressure are associated with poor acid reflux control after sleeve gastrectomy. This is particularly important in Lap Band to sleeve conversion cases. Lap band over-restriction damages esophagus function. Luckily we rarely see these cases now since gastric banding for weight loss is no longer performed.

#### Parsley: A Vibrant Vegetable with Tremendous Health Benefits
Parsley, a relative to celery, is a very popular herb all over the world. Parsley, however, is mostly used as a garnish except in certain countries like Lebanon where parsley is the main ingredient of a very famous dish: Tabouli.

Tabouli salad is a traditional Lebanese dish with incredible health benefits and unrivaled taste. It is made of chopped parsley, tomatoes, and onions. The dressing is olive oil and lemon juice. This simple combination of ingredients is probably the healthiest food item I am aware of due to the nutritious ingredients of parsley. Indeed, parsley is not only nutritious but also healing. Rich in vitamin C, parsley has been shown to protect against rheumatoid arthritis. At the same time, parsley is a good source of folic acid, an important vitamin for cardio-vascular health. Volatile oils in parsley like myristicin, inhibit tumor formation. Furthermore, parsley is rich in a number of antioxidants like luteolin, that prevent cell damage and improve longevity. Finally, parsley improves digestion and is a great muscle relaxant.

Houston weight loss surgery center endorses Tabouli as one of the healthiest salads to have prior to weight loss surgery to improve cardio-vascular function, cleanse the body, lose weight, replenish essential vitamins and promote healing after laparoscopic bariatric surgery. Following gastric sleeve or gastric bypass surgery, Tabouli is a great meal or snack to have. It is a filling, nutritious, delicious and easy to prepare meal. Houston Weight Loss Surgery Center dietitian recommends adding raw and shelled hempseeds to Tabouli instead of the traditional cracked wheat. A serving of hempseed contains 10g of proteins and 3g of Omega-3 fatty acids. For those who follow a gluten free diet, hempseed substitution is a great alternative to cracked wheat. I have personally tried hempseed Tabouli and found it delicious.

#### Patient Education: Gastric Balloon and Portion Control
Pamela sent us this question regarding intra-gastric balloon mechanism of action: I am looking into getting a balloon placed into my stomach to learn portion control. I eat healthy and exercise regularly but I have failed to lose weight over the past few years.

Thank you, Pamela, for your question and interest in our comprehensive weight loss program at Houston Weight Loss Surgery Center. Your question is very important, and in my opinion it underlies a central concept in weight loss and bariatric surgery mechanism of action. Indeed, there is more to bariatric surgery than simple calorie restriction and herein lies it effectiveness and durability.

Weight loss surgery like gastric sleeve procedure is also called metabolic surgery because it alters several hormones in your body. Hormones like Ghrelin, Leptin, PYY and GLP-1 control your energy metabolism, appetite, hunger and weight. Thus, following gastric sleeve surgery, Roux-en-Y gastric bypass, or duodenal switch surgery, altered hormone secretion leads to increased metabolic rate, decreased hunger and appetite, and increased satiety. You are now satisfied with a small meal not only because your stomach volume has decreased but also because your satiety has increased. Procedures like gastric balloon and lap Band are purely restrictive. This means that your gastric volume is reduced forcing you to eat less without altering any of the hormones that control your weight and appetite. Thus, you are not satisfied with a small meal even though you are making every possible effort to learn and apply portion control.

Weight loss is not a will power or behavioral problem. Weight loss is a hormonal problem. Bariatric surgery resets your energy hormones allowing you to be satisfied with small portions. Enforcing portion control by itself, leads to starvation. Starvation leads to increased hunger and decreased metabolism. Hunger is not easy to ignore and low metabolism trigger fat cells to absorb and hoard too many calories. The result of calorie restriction is eventual weight regain and frustration. A phenomenon that you and most Houstonians experience daily.

“Overeating doesn't make you fat. The process of getting fat makes you overeat,” per David Ludwig, a practicing endocrinologist at Boston Children’s Hospital and a professor of nutrition at the Harvard School of Health in Boston. In his book, “Always Hungry”, Dr. Ludwig emphasizes that body weight is about biology rather than willpower. The key to weight loss is not discipline but getting your metabolism to work correctly. Gastric balloon and Lap Band procedures do not correct your metabolism. You may be forced to eat small meals while the balloon is in place and loose around 20 pounds. However, once the balloon is removed 6 months after placement, you are most likely going to regain the weight back despite your best efforts.

#### Persistent Gastroparesis Following Gastric Sleeve Surgery
Nathali from South Florida sent us this question this week:
Question
I was diagnosed one year ago with moderate Gastroparesis after I have been suffering with gastroenterology issues for over 10 years. I’ve seen many different GI’s. I had my gallbladder removed in 2015 (since my pain was always located in that area, my HIDA scan was borderline). In 2016, I had gastric sleeve surgery (I was over 285lbs, my PCP thought this was causing GI issues). After gastric sleeve my usual gallbladder area pain/nausea got worse. After many ER visits, I was started on Reglan/ Domperidone. Didn’t help. I was then referred to Cleveland Clinic where they told me it was highly unlikely that I had Gastroparesis (not based on any medical check-up, just the doctor’s opinion). After gastric emptying test diagnosed me with moderate Gastroparesis.

I followed dietary restrictions and am mostly on soft foods. After several ER visits this year, feeling sick every day and spending most of my days in bed since I don’t have much energy left, I sought out Dr. Rose for a gastric pacemaker (after much research). I was told I was not a candidate for the pacemaker since I had sleeve surgery and that my best option would be revision to bypass. After 2 months of tests to prepare me for bypass revision surgery, I was told this week that instead of revision surgery they want to try the pacemaker after all. This confused me since I was told previously, I wasn’t a candidate.

I had endoscopy 2 weeks ago and was told I also have bile reflux. After research, I read that bypass revision can help to resolve Gastroparesis issues, it can solve constant nausea and it has been proven to relief bile reflux. The pacemaker only seems to be helpful against nausea. I saw your article about Gastroparesis and would love to get your input.

Thank you!
Answer
Dear Nathali,

I have been quite fortunate over the past few years to meet and successfully treat several gastroparesis patients. The first patient I treated in 2010 had severe refractory gastroparesis with advanced symptoms including daily vomiting, dehydration, and electrolyte abnormalities. I performed a longitudinal gastric resection that preserved the antrum and added a duodeno-jejunostomy because this patient had a dilated duodenum. Amazingly, he did very well. His symptoms completely resolved immediately following surgery and he was able to go back on a regular diet again. I published this case report in SOARD journal under the title of “Laparoscopic longitudinal gastrectomy and duodeno-jejunostomy for treatment of diabetic gastroparesis”.

The rationale behind this approach to treating gastroparesis is the fact that sleeve gastrectomy performed for morbid obesity has been shown to increase gastric emptying. I took this concept, modified the sleeve surgery to preserve the antrum (gastric pump) and applied it to several gastroparesis patients over the past few years with great success. Postoperatively, nausea, bloating, vomiting, and pain resolved, and gastric emptying improved.

Randomized controlled studies have shown that gastric pacing is not an effective treatment for gastroparesis. Physicians still use this approach because there are no published guidelines for treatment of gastroparesis. The theory behind gastric pacing and its presumed mechanism of action make no sense to me. I think gastric pacing is a futile and naïve approach to gastroparesis treatment.

Gastric bypass surgery may work in mild gastroparesis cases. Gastroparesis is a generalized gastro-intestinal motility disorder. Bypassing or resecting the stomach is not an effective solution for delayed gastric emptying. The few published reports about gastric bypass surgery for treatment of gastroparesis including one recently published by Dr. Rosenthal in SOARD journal: “Surgical Management of Gastroparesis: A Single Institution Experience”, show modest symptom improvement. In this report the author concludes that gastric pacing is more effective than gastric bypass at alleviating pain due to gastroparesis. Probably, this is the reason you were offered gastric pacing first.

Both delayed gastric emptying and the presence of a hiatal hernia increase the likelihood of gastric content reflux into the esophagus (it can be bile or acid or both). Narrowing of the sleeve lumen and large residual gastric fundus are additional risk factors for reflux. Poor esophageal motility further exacerbates reflux symptoms and reflux induced damage of the esophagus.

I recommend a comprehensive evaluation and workup before making any decision. If the sleeve can be salvaged, then this would be your best option. If the sleeve cannot be salvaged, then conversion to gastric bypass may help you especially if you have a mild case of gastroparesis. Gastric pacing in the setting of a gastric sleeve has not been described to the best of my knowledge and I am not sure if it will work.

Healthy Regards,

Dr. Darido

 

#### Persistent Heartburn after Gastric Sleeve to Bypass Conversion
Jennifer from Houston sent us this question: “I just had conversion from sleeve to bypass along with hiatal hernia repair for GERD. It's been a month. Started having reflux again about 2 weeks out ?”.

Dear Jennifer,

I am not sure what do you mean by having “reflux” again. Acid reflux is a medical disease diagnosed by an acid reflux specialist. Reflux is not a symptom. Heartburn, food regurgitation, cough, globus and epigastric pain are symptoms commonly experienced by patient with acid reflux disease. Symptoms however do not always correlate with acid reflux disease presence and severity. Therefore, the first thing I recommend to patients with recurrent acid reflux related symptoms after anti-reflux surgery, is to repeat upper endoscopy with ambulatory pH testing. 24-hour pH impedance may be added to check for non-acid reflux especially in the case of gastric bypass.

Gastric bypass is an effective anti-reflux procedure. Fast gastric pouch emptying into alimentary limb contribute to acid reflux control. Furthermore, diverting most of the stomach acid away from esophagus further add to acid reflux control.  A short alimentary limb may result in bile reflux into esophagus. Treatment in this case consists of lengthening the alimentary limb. A gastro-gastric fistula, a connection between remnant stomach and gastric pouch may also lead to acid reflux. This condition is less likely to occur in cases of sleeve to bypass conversion. Lastly, if your bariatric surgeon resected most of the remaining gastric sleeve during sleeve to bypass conversion, a retained gastric antrum syndrome may occur. Retained gastric natrum syndrome is characterized by elevated gastrin levels in the blood. Gastrin stimulates acid secretion in gastric pouch. Gastrin hormone is secreted by G cells located in stomach antrum. Stomach acid inhibits gastrin hormone secretion. An unresected gastric antrum constantly exposed to bile from the duodenum and no acid from the stomach, may lead to elevated gastrin hormone blood levels. Treatment in this case consist of gastric antrum resection.

Irrespective of cause, proper evaluation by an acid reflux specialist and bariatric surgeon in Houston is highly recommended to choose the most effective solution for your problem.

#### Persistent Heartburn Following Sleeve to Bypass Conversion
Sally from Katy, Houston, TX sent us this question: “I had gastric sleeve in 2016. Gallbladder removed 2017, and now a revision into a Gastric bypass in 2021. I've had corrosive esophagitis and GERD for who knows how long, but I was diagnosed last year. Even though they repaired my hiatal hernia in April along with the sleeve to bypass revision... why do I still have GERD? It doesn't make sense. I was given Protonix after surgery which I had been taking since then (April) but I realized it has been causing me a very slow digestion to the point of not being able to eat. I stopped Protonix and found I can finally eat but now all of my GERD symptoms have come back. My Bariatric office had me contact my GI doctor. GI gave me Dexilant 30mg and we've got an Endoscopy scheduled for next month. I just want answers or a suggestion since I'm tired of being miserable”.

Dear Sally,

A poorly performed gastric sleeve surgery is a recipe for acid reflux development. Narrowing the area where the horizontal and vertical parts of the stomach meet, during gastric sleeve surgery, creates a functional obstruction. This results in backflow of acid and bile from gastric sleeve lumen into esophagus. Acid reflux gradually leads to hiatal hernia development or gastric sleeve migration into chest which in turn worsens acid and bile reflux. As a result, corrosive esophagitis develops as you have mentioned.

Luckily, the narrowed mid portion of the gastric sleeve dilates over time. Functional obstruction, the primary cause for acid reflux, resolves. However, a hiatal hernia has already developed, and it continues to be a major cause of bile and acid reflux. Consequently, our initial approach to managing acid reflux after poorly performed sleeve gastrectomy is hiatal hernia repair. The majority of patients respond with excellent GERD symptom control with no need to convert gastric sleeve to gastric bypass. Should hiatal hernia repair fail to stop acid reflux we then recommend sleeve to gastric bypass conversion.

Gastric bypass is an excellent anti-reflux procedure. However, in the setting of gastric sleeve to gastric bypass conversion care must be taken to avoid bypassing most of the stomach. Bypassing most of the sleeved stomach diverts the acid secreting gastric body from gastric antrum. An alkaline environment in gastric antrum leads to excessive gastrin hormone secretion. Increased amounts of gastrin stimulate excessive acid secretion in gastric pouch. Some of this acid escapes into the esophagus, and results in acid reflux related.

Work-up include blood gastrin level, upper endoscopy and ambulatory pH testing. Treatment requires gastric antrum resection to decrease gastrin levels and reduce acid secretion.

#### Pokemon Go: Get Up and Go
Released in July of 2016, Pokemon Go app, has gained lot of popularity in 30 different countries around the world. The game concept is based on the real outside world. For the first time, technology is nudging millennials to get off their couch and move around their neighborhoods. Last week I wrote a blog on the importance of daily walking and how technology and our modern city structures prevent us from walking. Our sedentary lifestyle greatly contributes to the obesity and diabetes epidemic especially among teenagers. Pokemon Go is a great tool to motivate individuals to go out and become more active.

Apps like Pokemon Go may be part of future solutions to curb the obesity epidemic. The Internet has become an integral part of our life. Why not use it to improve our health in cities like Houston? Rather than developing apps and games that isolate us from one another and confine us to dark rooms and virtual realities, newer apps ought to do the opposite. Augmented reality apps may indeed be a more natural option for our well being. Transforming our smartphone, a device that promotes laziness and disconnection from our surroundings, is a good thing. Walking a few miles a day, getting some sun exposure, breathing fresh air, and socializing with neighbors is simple yet vital to our physical and mental health.

I am hoping to see more app development along those lines that motivate and encourage humans at a subconscious level to get up and move. Improving our neighborhood walk-ability while encouraging our citizens to move may prove to be an effective approach for preventing weight gain and associated diseases.

#### Post-Sleeve GERD As A Weight Loss Predictor
I read with great interest a new study by Luigi Angrisani, M.D. et al that was recently published in SOARD, Surgery For Obesity And Related Diseases. It is a small size retrospective study with a 5-year follow-up period. 105 obese patients underwent gastric sleeve surgery with excellent weight loss outcomes at 5 years and significant improvement in multiple obesity associated co-morbidities.

The authors showed that weight loss was lower in patients with postoperative GERD. They also found that concomitant hiatal hernia repair with sleeve gastrectomy did not increase postoperative GERD remission. Two patients underwent revisional surgery for severe postoperative GERD. Both patients had already received concomitant sleeve and hiatal hernia surgery. One of those two patients showed hiatal hernia recurrence on double contrast barium swallow prior to surgery while the other showed signs of reflux.

The strength of evidence in supporting lack of benefit of concomitant hiatal hernia repair and sleeve gastrectomy is weak in this study due to small sample size. However, the finding of post-operative GERD as a predictor of weight loss following gastric sleeve surgery is quite interesting. The authors attributes this finding to insufficient postoperative weight loss leading to acid reflux. However, the underlying pathophysiology of GERD and its relationship to obesity is much more complex. In my opinion, post-operative GERD is secondary to a poorly performed gastric sleeve. A retained gastric fundus will lead to both poor weight loss and acid reflux. A recent study has shown that a gastric sleeve that is too narrow is associated with increased incidence of GERD and poor weight loss. In other words, GERD and poor weight loss go in hand in hand following a poorly constructed sleeve. This finding is independent of whether a hiatal hernia is present or not. Finally, I think that a large hiatal hernia must be properly repaired in order to prevent post-sleeve GERD. Hiatal hernia repair is quite challenging in the obese patient especially in those patient with a BMI higher than 50. Extensive distal esophageal dissection and mobilization is required to properly fix a hiatal hernia. There is great variability in technique and approach to hiatal hernia repair among surgeons resulting in controversial conclusions in most studies addressing concomitant hiatal hernia repair and sleeve gastrectomy. At Houston Weight Loss Surgery Center, we advocate the proper repair of a hiatal hernia in gastric sleeve cases. For super morbidly obese patients, BMI more than 50, staging the procedure is beneficial. We perform a gastric sleeve first and after 6 months to one year we repair the hiatal hernia.

#### Pre-Op Liver Reduction Diet
In preparation for your surgery, a low calorie, high protein diet is recommended two weeks prior to your weight loss surgery.  This program will promote weight loss and will reduce the liver size to make your procedure technically easier for your surgeon.
Download the diet plan here.

 

#### Processed food and Weight Gain after Gastric Sleeve
The National Institute of Health, NIH, conducted a prospective randomized study on a group of twenty healthy volunteers, average BMI=27. The recruits were randomly divided into two groups. First group of individuals consumed a diet of ultra-processed food for two weeks then unprocessed diet for two more weeks. The second group followed the same course but started with unprocessed diet then ultra-processed diet. Meals for each diet were prepared by dieticians to match in terms of calories and macronutrient content. Volunteers were allowed to consume as much or as little as desired. The study was recently published in the journal of Cell Metabolism.
The authors found that energy intake was greater during the ultra-processed diet with increasing consumption of carbohydrates and fat but not protein. Weight gain of around one kilo occurred during the ultra-processed diet period and highly correlated with increased energy intake. The authors conclude that eliminating ultra-processed diet, a less expensive and more convenient meal for thousands of Houstonians, decreases energy intake and results in weight loss.
This study further confirms our most important treatment recommendation at Houston weight loss surgery center: Not all calories are created equal. The first step in your weight loss journey is eliminating the ultra-processed food items from your diet. It is a hard step for many Houstonians, yet so crucial to achieve durable weight loss especially in the setting of gastric sleeve surgery. In my experience, the most common cause of weight regain after gastric sleeve surgery is the resumption of processed food intake. Gastric sleeve patients who stop cooking at home and resort to frozen foods and restaurant meals are at great risk of gaining back significant amount of weight. Ultra-processed diet disrupts the gut-brain axis that control appetite, satiety and food processing leading to increased energy intake and weight regain.
The industrialization of food and the increased consumption of highly processed meat, dairy and refined wheat products have greatly contributed to the obesity epidemic. Many theories have been proposed to establish a cause and effect relationship between processed diet and obesity. This study helps further confirm and better understand the effect of processed food on weight gain.

#### Protein Shake Recipes To Support Your Recovery After Sleeve Surgery
During the first few weeks after gastric sleeve, you need proteins to heal and recover from surgery. A minimum of 60 grams of proteins are needed daily. Some examples of high protein food items include meat, cheese, eggs, beans, tofu, yogurt, milk, and nuts. Since your stomach is smaller now, you need to make sure you get at least 10 to 15 grams of proteins per meal. Your meal will initially consist of full liquids and a protein shake is a great way to get the proteins you need. Try to have several small meals throughout the day. Get your proteins first then think about the carbohydrates. Several weeks after surgery, you can get all your daily protein needs from regular food. You can still use protein shakes as snacks or meal replacements. However, bariatric surgery is not about living on protein shakes for the rest of your life. Healthy eating after weight loss surgery is of paramount importance to ensure durable weight loss. Healthy eating, however, is more fun and much more diverse than a protein shake. In the subsequent blogs for this month, I will go over the concepts of proper nutrition after sleeve or bypass surgery. For now, please enjoy these protein shake recipes.
Berry Bomb
1 scoop of whey protein isolate (vanilla)
½ cup of diet cran-grape juice
½ cup approved milk of your choice
½ cup frozen blueberries
Chocolate-Covered Strawberry
1 scoop of whey protein isolate (chocolate)
1 cup approved milk of your choice
½ cup frozen strawberries
Far-out Fruitopia
1 scoop whey protein isolate (vanilla)
1 cup approved milk of your choice
¼ cup fresh or frozen mango
¼ cup fresh or frozen pineapple
Strawberry-Banana Smoothie
1 scoop whey protein isolate (vanilla)
1 cup approved milk of your choice
¼ cup fresh or frozen strawberry
¼ cup fresh or frozen banana
Apple Pie
1 scoop whey protein isolate (vanilla)
1 cup approved milk of your choice
¼ cup unsweetened applesauce (may freeze in cubes)
¼ tsp ground cinnamon
Green Goddess
1 scoop whey protein isolate (chocolate)
1 cup approved milk of your choice
1 tbsp unsweetened cocoa powder
¼ frozen banana
¼ cup frozen blueberries
1 cup leafy greens (spinach)
Watermelon-Basil Smash
1 scoop whey protein isolate (vanilla)
1 cup approved milk of your choice
¼ cup frozen (cubed) watermelon
2-3 leaves fresh basil
½ cup fresh spinach
Cucumber-mint Cooler
1 scoop whey protein isolate (vanilla)
1 cup approved milk of your choice
7 frozen grapes
½ cucumber (preferably frozen)
2-3 fresh mint leaves
 

#### Public Service Announcement from the American Society for Metabolic and Bariatric Surgery (ASMBS)
ASMBS has just announced that Ethicon Endo-Surgery will discontinue the production of Gastric Band device for weight loss. ASMBS and FDA continue to endorse gastric banding as a weight loss procedure. Adjustable gastric banding is rarely being performed these days in Houston and all over the country. The procedure that has gained so much popularity few years ago has proven to be an ineffective approach to durable weight loss. Gastric banding, a purely restrictive procedure, has become the ultimate proof that gastric volume reduction by itself is not a weight loss procedure associated with durable weight loss. Calorie restriction is no longer accepted as an effective weight loss solution.

Apollo Endosurgery, Inc. continues to manufacture the Lap Band device. ASMBS continue to endorse gastric banding as an effective weight loss procedure. I don’t have an explanation behind this endorsement. I think it is time for ASMBS to update their guidelines and save new patients from falling victims of a weight loss procedure that has proven to be not only ineffective but also detrimental to esophageal motility. Indeed, gastric banding results in dilation of the distal esophagus and hiatal opening. It damages esophageal motility and results in severe acid reflux disease. We continue to deal with lap band complications and frustrated patients on a weekly basis. Let’s stop the damage today.

The ASMBS holds a central role in guiding bariatric surgeons across the country and in educating the public on obesity treatment. The ASMBS ought to help develop novel effective and safe weight loss procedure while outdating and denouncing current weight loss procedures that do not work. Our knowledge of obesity and energy metabolism has greatly evolved over the past few years. We can no longer accept weight loss procedures based on wrong outdated assumptions from the past. Obesity treatment paradigms will continue to evolve and I wish ASMBS remains a leader in our field, approving the right weight loss procedures and disproving those that do not work.

#### Pyloric Drainage and Gastroparesis
A recent study titled “Does pyloric drainage have a role in the era of minimally invasive esophagectomy?” and published in Surgical Endoscopy journal, caught my attention. The authors retrospectively analyzed 283 patients undergoing minimally invasive esophagectomy in a single institution. Almost half the patients underwent pyloric drainage (53 with botulinum injection and 73 surgical). Pyloromyotomy or pyloroplasty has historically been performed to prevent delayed gastric emptying following vagal nerve transection during esophagectomy. Gastric stasis results in nausea and vomiting, increase the risk of aspiration pneumonia, and anastomotic leak.

The authors, however, found no difference in the 90-day post-operative complication rate between patients with and without pyloric drainage. Furthermore, at 6 and 12 months after surgery, patients who received botulinum injection or surgical drainage had significantly more symptoms than no drainage and higher need for pyloric dilation.

I like this study because it highlights the inefficiency of stomach drainage procedures like pyloroplasty for treatment of delayed gastric emptying and gastroparesis. One would assume that in the setting of vagal nerve injury delayed pylorus hypertonicity is the underlying cause of delayed gastric emptying. Consequently, a pyloroplasty would promote gastric emptying and alleviate symptoms. This study, however, and several others show the opposite. Gastroparesis has a number of etiologies and varying pathophysiology. However, if pyloroplasty is not an effective gastroparesis treatment in the setting of vagal nerve injury, it not likely to be work in other settings for refractory gastroparesis. A number of studies have been published over the past few years about the effectiveness of endoscopic pyloroplasty (G-POEM) for treatment of medically refractory gastroparesis. I seriously doubt these results and I advocate the use of antrum preserving longitudinal gastrectomy (modified sleeve gastrectomy) to promote gastric emptying as described in previous blogs.

 

#### Question about Nissen Fundoplication
An Interesting and important Question from Julie. She writes:

Hello and thank you for this article.

I am currently scheduled to have the Nissen fundoplication w/ hiatal hernia repair after being sleeved last Nov 11/13/15. I never had heartburn of any kind before the sleeve. About 2 months after my surgery I started experiencing severe GERD w/ regurgitation. We tried Carafate, Reglan and PPI's. I improved w/ medicine until late Oct and after adding OTC meds & other antacids along w/ the twice a day max dose of PPI's I am now having chest pain, a lump in my throat and regurgitate at least once a day sometimes more than once.

I had another upper GI a few weeks ago and regurgitated twice when they laid me down after just drinking the thin barium. We could not even proceed w/ the other barium.

The report stated my GERD was Severe multiple times, they actually said it was "Profound." I have read a lot about this surgery in patients who have not had gastric surgery and many gastric patients that had a hiatal hernia repairs when the sleeve was performed but your article is the closest I can find with all three.

I am very nervous for a few reasons. There is only so much stomach my surgeon has to work with so it seems like it will not be the typical Nissen Fundoplication w/ hernia repair. I am scared that I will have trouble swallowing, that the surgery will be difficult, I am scared of having to convert to open, I am scared of getting sick from the anesthesia and it affected the surgery, I am scared of not being able to eat much and losing more weight. I am comfortable at 140 now.

Anyways, are you able to share any additional experience with a one year post op sleeve patient that will be undergoing this surgery? My surgery was done in the States by the way.

My surgeon blocked off 3.5 hours OR time and it sounds like recovery will be about 2 weeks before I can return to work if done laparoscopic. Does that sound right?  I am trusting that the benefits will outweigh the risks and down time b/c at this rate I will get barretts and possibly esoph. cancer.  

Thank you for your time!
 Julie

Dear Julie,

Your question and concerns are quite relevant. New onset acid reflux or GERD following gastric sleeve surgery is an important issue that is subject to lot of debate among bariatric surgeons. I happen to specialize in both acid reflux and weight loss surgery. I am very interested in this issue. At Houston Weight Loss Surgery Center, I treat acid reflux disease in overweight individuals by performing a hiatal hernia repair with gastric sleeve surgery. I have had great results and I believe that a properly performed sleeve and hiatal hernia should not lead to increased or new onset acid reflux disease.

Patients who present to my office with post gastric sleeve acid reflux undergo extensive workup including upper endoscopy, pH impedance, esophageal manometry and upper GI contrast study. We try to delineate the cause of acid reflux before embarking on any type of revision surgery.

There are several causes for acid reflux after sleeve surgery:

1. Unrepaired hiatal hernia
2. Poorly repaired hiatal hernia during gastric sleeve surgery
3. Retained gastric fundus
4. Narrowed gastric sleeve lumen especially at the incisura angularis (where the stomach naturally bends)
5. Twisted gastric lumen

There are many options to correct the problem depending on the underlying cause. In cases where there is gastric sleeve narrowing, a gastric bypass is the only solution.

Nissen fundoplication or 360-degree wrap is, theoretically, not feasible after gastric sleeve surgery. There is not enough gastric fundus to wrap around the entire esophagus. Your surgeon may be offering you a partial anterior or posterior fundoplication. There are few reports in the literature about the efficacy of such an approach in controlling reflux in the setting of gastric sleeve surgery. I have personally not tried this approach.

I hope these general guidelines are of help to you. Should you have any additional questions or concerns please do not hesitate to discuss with your bariatric surgeon prior to surgery.

Warm Regards,

Dr. Darido

#### Question of the Month
Lauren sent us this question few days ago:

“I had gastric sleeve surgery in June 2015. I recently had an unrelated x-ray of my back and found out I have a hiatal hernia. I had heard before the surgery and after. Could the surgery have caused the hernia? Is there anything I should do about it? Also, I had 80 pounds to lose and only lost 50 in 1.5 years. My stomach has stretched a little. What should I do to lose the weight? Thank you”

Thank you, Lauren, for your important and interesting question. Hiatal hernias and acid reflux are very common in overweight individuals. At Houston Weight Loss Surgery Center, we carefully investigate the hiatal area before and during gastric sleeve surgery to make sure we address the issue. It is important to properly fix a hiatal hernia during gastric sleeve surgery for several reasons. First, by dissecting the hiatal hernia, the gastric fundus is completely free of surrounding adhesions. A completely mobilized gastric fundus is crucial to ensure proper sleeve resection. Incomplete fundus resection leads to poor weight loss and post-operative acid reflux. Second, a hiatal hernia in the setting of gastric sleeve surgery leads to acid reflux disease as well as bile gastritis. Two conditions that cause significant pain and discomfort after surgery. Third, if the hiatal hernia is not fixed during gastric sleeve surgery, then the sleeved stomach will tend to migrate into the chest with time. Such a condition will further exacerbate acid reflux, difficulty swallowing food, and bile reflux.

Does gastric sleeve surgery by itself cause a hiatal hernia? The answer is No. However, if the hiatus is partially dissected during gastric sleeve surgery to fix a hiatal hernia or for other reasons then you are put at risk for hiatal hernia development with time.

Is there anything I should do about it? If you are not experiencing heartburn, food regurgitation, pain, nausea... then there is no need to repair the hernia. I would recommend an upper endoscopy to evaluate the distal esophagus for distal esophagitis, and the stomach for bile gastritis. Upper endoscopy is a more sensitive test than X-ray to evaluate a hiatal hernia.

Regarding your weight loss, many factors contribute to poor weight loss after gastric sleeve surgery. I strongly recommend you follow up with your bariatric surgeon to explore the reasons behind your poor weight loss. In certain cases, gastric sleeve revision or conversion to gastric bypass is recommended.

Warm regards,

Dr. Darido

#### Question of the Week from Tina
Question of the Week from Tina:

I’m planning on having VSG in the next three months. I had the Nissen funoplication 3 yrs ago for severe Gerd. My consult will be sometime next month. It seems that there is no contraindication for gastric sleeve after the nissen procedure, according to this article which is a relief to me. It seems nissen reversal prior to VGS would be a much riskier procedure. Will there be enough of the “hunger hormone” side of the stomach to surgically remove and can this side of stomach grow back? Or does it just stretch itself back out if one tends to over eat?

Excellent question Tina. Ghrelin or hunger hormone is mostly secreted by gastric fundus. Ghrelin blood level decreases following gastric sleeve surgery as the gastric fundus is resected. Decreased ghrelin levels contribute to hunger control, increased satiety and weight loss. We don’t have any study evaluating Ghrelin blood level following Nissen Sleeve surgery. I think that a plicated gastric fundus is metabolically equivalent to a resected fundus. Therefore, I expect Ghrelin level to decrease following Nissen Sleeve surgery. Nissen fundoplication is associated with weight loss and a recent study published in 2015 demonstrated decreased Ghrelin levels following fundoplication surgery. Gastric fundus invagination, a weight loss procedure I developed few years ago, prevents Ghrelin level increase with weight loss. I demonstrated this finding in an obese rat model. In humans, gastric fundus invagination has not been studied but I predict that Ghrelin levels will also decrease.

Ghrelin, however, is not the only hormone change responsible for weight loss. Many other signals are equally important like GLP-1 (Glucagon like peptide). GLP-1 decreases following Nissen fundoplication and is likely to decrease following Nissen Sleeve surgery. Increased gastric emptying is thought to contribute to GLP-1 increase and Nissen fundoplication is associated with increased gastric emptying. I have noticed on post-operative contrast studies that Nissen Sleeve procedure increases gastric contrast emptying.

Overall, I think that the plicated fundus is functionally equivalent to a resected fundus. When properly performed, fundus presrving gastric sleeve surgery, in obese patients with history of Nissen fundoplication, results in excellent weight loss results.

#### Question of The Week: Acid Reflux Following Sleeve
I had sleeve surgery about 2 years ago in Dallas. I’ve lost about 40 pounds and still eat pretty small amounts but can't seem to lose more. I’m about 158 pounds now. I suffer from horrible GERD. Sometimes bile comes into my throat while I’m sleeping and I feel like I’m choking on acid. I'm 44 and take Dexilant, Nexium, Prevacid, alka seltzer, and tums daily. I’m worried about all this medication and my symptoms seem to be getting worse. Thank you

Dear L.,

Your symptom description is highly suggestive of severe GERD post sleeve gastrectomy. A well performed sleeve gastrectomy is expected to resolve acid reflux rather than cause it. I suspect you have a missed hiatal hernia that can be easily corrected. An upper endoscopy as well as upper gastrointestinal contrast study are needed to study the anatomy of your stomach and esophagus. If the sleeve lumen is twisted, narrowed or dilated additional surgery may be needed to correct the problem.

Dexilant, Nexium, Prevacid and other antacid medications are not an effective solution in your case. Bile reflux is very common in missed hiatal hernia following gastric sleeve surgery because the sleeve lumen is rigid and non-compliant. As a result, the negative intra-thoracic pressure is easily transmitted into the sleeve lumen. This creates a suction effect that facilitates the retrograde flow of bile from the duodenum into the gastric lumen and esophagus. Almost every gastric sleeve patient I evaluate for post-operative GERD has evidence of bile gastritis. I have had great success alleviating both bile reflux and bile gastritis by properly repairing a missed or poorly dissected hiatal hernia in sleeve gastrectomy patients. If you had gastric sleeve surgery and currently suffer from acid reflux disease please give us a call. There is no need to suffer and ruin your weight loss journey.

#### Question of the Week: G-POEM for Gastroparesis
Shabir asked: “I like to know right at this moment how long will it be when everyone who suffers from diabetic gastroparesis will get a g poem procedure when that seems to be the best solution and another thing I like to ask is why is there so little treatment options for diabetic gastroparesis in this day and age when there are so many people suffering. Thank you looking forward to hearing from”.

Dear Shabir,

G-POEM stands for gastric per-oral endoscopic myotomy. The pyloric muscle is cut open using special endoscopic instruments inserted through the mouth. The advantage of such an approach over traditional pyloromyotomy is lack of incisions. This translates into faster recovery due to decreased post-operative pain and discomfort. That doesn’t mean, however, higher success rate for treatment of gastroparesis. Gastric drainage procedures like pyloroplasty and gastro-jejunostomy are associated with more failure than success rates. Gastroparesis is a heterogeneous and complex motility disorder. Curing gastroparesis entails re-establishing some form gastric motility to favor gastric content emptying. Pyloroplasty whether it is done open, laparoscopic or endoscopic, does not restore motility. Consequently, food lingers in the stomach and does not empty in most cases. Adding a fundoplication increases the success rate of pyloroplasty. Adding a gastric body resection along the greater curvature and moving the pacemaker towards the antrum and possible resetting the Magenstrasse emptying pathway seem to be the most effective solution for gastroparesis. Unfortunately, this observation is limited to my personal experience dealing with a number of gastroparesis cases over the past 10 years of my professional career. I cannot pretend that I have the cure for gastroparesis. Nonetheless, the success rate of my surgical approach, antrum preserving modified longitudinal gastrectomy, in this small group of gastroparesis patients was 100%.

The incidence and prevalence of gastroparesis is expected to rise secondary to the diabetes epidemic. You are absolutely right, not much research is conducted in this field. Gastrointestinal dysmotility is a crucial player in the pathogenesis of obesity, type 2 diabetes, and GERD. All 3 diseases have reached epidemic proportions in this day and age. Deciphering the complexity of gastric emptying and the pathogenesis of gastroparesis is needed to help patients. So far, we have more questions than answers. Unfortunately, we still don’t have clear guidelines for effective gastroparesis treatment.

#### Question of the week: Sleeve surgery after Fundoplication surgery
Question of the Week:

Hello,

I am a 54-year young woman. I am 5'6" and 244 lbs. I had fundoplication surgery approximately 18 years ago in Cincinnati, Ohio.

I would like to have the sleeve surgery and I'm told that I can't have it due to the fundoplication surgery. This is such devastating news for me.

I have osteoarthritis, low thyroid, asthma. I'm taking metformin 500 mg/2 x daily along with a Trulicity injection 1x weekly for weight loss.

I am a flight attendant and I can feel the stress on my body from my weight. I would give anything to not have the joint pain that I do. I do not want to become a diabetic. I also want to feel better about myself.

I would appreciate any help that can be provided to me.

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Dear Patti,

Fundoplication surgery is not a contraindication for weight loss surgery in the form of gastric bypass or sleeve gastrectomy. Weight gain with age is common and while fundoplication surgery is an excellent solution for GERD it does not protect against obesity. Typically, we perform a wrap take down prior to sleeve gastrectomy or gastric bypass surgery. In certain cases, the wrap is adherent to surrounding tissue and it is difficult to safely dissect it. In such cases, gastric bypass can be performed with excellent weight loss outcomes while preserving the wrap. The gastric pouch is simply created below the fundoplication. In the case of Sleeve gastrectomy, stomach resection can be performed up to the level of the fundoplication. However, we don’t have any long-term data in terms of weight loss outcomes with such an approach. Complete gastric fundus resection is crucial when it comes to proper sleeve resection. Whether a wrapped fundus is equivalent to a resected gastric fundus in terms of weight loss remains to be determined. Few months ago, a French group of surgeons reported on their experience with the N-Sleeve. The study was published in SOARD (Surgery of Obesity and related Disorders). N-Sleeve is a Nissen fundoplication added to sleeve gastrectomy procedure offered to patients with severe GERD. The authors reported short-term weight loss results comparable to a traditional gastric sleeve surgery. Additional studies are needed to confirm these findings. I personally think that a wrapped gastric fundus like a resected fundus is functionally inactive. Gastric fundus invagination, a novel weight loss procedure I have developed, functions along the same line of thought. An invaginated gastric fundus is incapable of stretching and dilating to accommodate a meal. In an obese mouse model, Ghrelin did not increase following gastric fundus invagination in response to weight loss indicating an inactive fundus. Should these results be confirmed, gastric fundus invagination is a less invasive approach to weight loss than sleeve gastrectomy. Sleeve gastrectomy mechanism of action remains to be determined. Until we do so, we can only rely on outcome studies and statistics to determine whether a wrapped fundus is equivalent to a resected fundus in the setting of gastric sleeve surgery.

#### Question of the week: What Would You Do for This Gastroparesis Case?
“56-year-old female, with type II achalasia, underwent a POEM procedure in 2015 by our experienced advanced GI guy. Then, developed terrible reflux post POEM (positive pH study while on PPIs, DeMeester score of 45). Then, underwent a lap hiatal hernia repair and Toupet fundoplication by another surgeon, and her reflux symptoms improved slightly for a while, then worsened again (another positive pH study on PPI's). On top of it all, now she's developed gastroparesis (95% retention at 4 hours). So, next, she's undergoing a G-POEM procedure, with very minimal improvement of her symptoms. Oh yeah, she also happens to test + for CYP2C19 mutation and is a rapid metabolizer of PPIs. So, she's upped to Protonix 80mg TID by now, with poor symptomatic control and has objective evidence of LA Grade C esophagitis. As far as gastrinoma workup: Gastrin level of 700 on a PPI and negative secretin stimulation test.

What are the options now? Redo wrap? Anyone would convert her to a Roux-en-Y and if yes, how to minimize her (almost guaranteed) marginal ulcer formation? Mini-gastric pouch, vagotomy, etc? Her BMI is 17 and her main (worst) symptom is heartburn”.

This case was posted by a colleague on the SAGES Foregut Surgery Masters Program Collaboration Facebook page. It attracted my attention for several reasons. First, it illustrates the occurrence of acid reflux disease following POEM treatment of achalasia. Second, it demonstrates the futility of pyloroplasty for treatment of gastroparesis. Third, it shows that gastroparesis and its effect on GERD remain a poorly understood disease by most foregut surgeons. There are no treatment guidelines for gastroparesis and gastric bypass is often advocated as a treatment option for gastroparesis. There is however, no evidence that gastric bypass is a good solution for gastroparesis.

I have performed a longitudinal gastrectomy or modified sleeve gastrectomy on several gastroparesis patients with excellent results. Even in the setting of a fundoplication, a longitudinal gastrectomy below the wrap level that preserves the gastric antrum promotes gastric motility and cure gastroparesis. Accordingly, I strongly advocate this approach to the patient presented without the need to undo or redo the wrap or complicate the situation by adding a gastric bypass to an already malnourished patient.

#### Restaurants and mindful eating
Brent decided to adopt the mindful eating approach when it comes to eating out with friends and family. It is a strategy he has adopted in preparation for his gastric sleeve surgery at Houston Weight Loss Surgery Center.

#### Robotic Gastric Sleeve Surgery
Robotic bariatric surgery is available in Houston for several weight loss procedures including gastric sleeve surgery. However, merits of the robotic approach compared to traditional laparoscopic surgery are still unknown. While the robotic approach may sound advanced and can be helpful in certain types of surgeries, studies have not shown clear benefits over traditional laparoscopy for gastric sleeve surgery. In fact, robotic sleeve surgery often takes longer, costs more, and may carry higher risks of complications.

“Robotic sleeve gastrectomy has higher complication rates compared to laparoscopic: 8-year analysis of robotic versus laparoscopic primary bariatric surgery” is a recent publication in SOARD (Surgery for Obesity and Related diseases) journal that shed some light on this subject. The authors conducted a retrospective analysis of 591118 gastric sleeve surgeries performed between 2015 and 2022. The percentage of gastric sleeve surgery increased from 6.7% to 29.5%. Robotic sleeve gastrectomy in this series was associated with a higher overall morbidity, as well as higher staple line leak and bleeding rates when compared to laparoscopic gastric sleeve surgery.

This study, despite its limitations, demonstrates that robotic gastric sleeve surgery offers no additional advantage compared to the laparoscopic approach and is associated with a higher complication rate. These findings further support our preference for laparoscopic techniques when performing sleeve gastrectomy due to their safety profile and efficiency. At Houston Weight Loss Surgery Center, our gastric sleeve surgery treatment protocol aligns well with technical findings that emphasize the benefits of laparoscopic surgery for stomach resection. This protocol prioritizes the use of standard laparoscopy due to its ability to perform the resection accurately and efficiently, with a focus on shorter operative times and lower costs compared to robotic methods, reflecting the current understanding and best practices in the field.

As you look for the best bariatric surgeon and practice in Houston, you may come across robotic sleeve surgery, which may sound high-tech and appealing. However, research shows that the traditional laparoscopic sleeve gastrectomy is safer, with fewer risks. That’s why we recommend the laparoscopic approach; it offers the best balance of safety, effectiveness, and peace of mind for our patients.

Lastly, it is important to know that “robotic surgery” is somewhat misleading. A robot is not operating on you independently. Instead, the surgeon is always in complete control, using a console to move mechanical arms to perform the surgery. The technology may sound futuristic, but every decision and every motion come from the surgeon—not the robot. In the end, your safety and outcome depend on the experience, judgment, and skill of your surgical team. If you have any additional questions about sleeve surgery in Houston, give us a call at 832-963-1803.

#### Rossetti Sleeve Gastrectomy
Laparoscopic sleeve gastrectomy combined with Rossetti fundoplication (R-Sleeve) for treatment of morbid obesity and gastroesophageal reflux by Stefano Olmi is a new study published online in SOARD (Surgery for Obesity and Related Disorders). 40 patients suffering from morbid obesity and acid reflux confirmed by either upper endoscopy or ambulatory pH testing were retrospectively analyzed. All patients underwent sleeve gastrectomy that spared part of the gastric fundus. the remnant fundus was used to perform a 1.5 cm, two suture, floppy fundoplication. Interestingly, hiatal hernia repair was only performed for large defects. The authors describe an unusual technique of opening the space between the esophagus and left crus to reduce small hiatal hernias without any suture repair.

Patients underwent an upper endoscopy at 12 months after surgery. Patients with preoperative esophagitis showed improvement and those without mucosal inflammation showed no new onset esophagitis. Repeat ambulatory pH testing was not performed. All patients were off proton pump inhibitors and 95% of them acid reflux related symptom free. Excess weight loss percent at 12 months was around 62%.

At Houston Weight Loss Surgery Center, we perform a formal hiatal hernia repair for all obese patients with GERD presenting for sleeve gastrectomy. We have found that a properly performed sleeve gastrectomy with distal esophageal mobilization and posterior hiatal hernia repair result in excellent reflux control. In my opinion, a resected gastric fundus is equivalent to a plicated fundus around the esophagus (fundoplication) in terms of preventing reflux. The assumption that a fundoplication works by reinforcing the lower esophageal sphincter (LES) is naïve. Fundoplication mechanism of action is much more complicated than LES reinforcement. Indeed, repeat esophageal manometry does not show increased LES pressure and most GERD patients undergoing Nissen fundoplication surgery have normal LES pressure. Acid reflux disease is a multifactorial problem. Gastric fundus wall compliance, relaxation and motility affect transient lower esophageal relaxation events and reflux episodes. Fundoplication surgery alters these factors in favor of reflux control. Similarly, fundus resection in sleeve gastrectomy prevents reflux and promotes gastric emptying. There is no need to add a fundoplication to a properly performed sleeve gastrectomy and hiatal hernia repair.

#### 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 been 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.

#### Should You Check for Hiatal Hernia before Sleeve Gastrectomy?
Kate from Houston sent us this question: “Do you guys offer testing for hiatal hernias? I've been considering gastric sleeve surgery, but I have severe heartburn and food regurgitation. Was thinking if I do have a hiatal hernia, might as well do both surgeries at once”.

Dear Kate,

Hiatal hernia testing and repair is an integral part of gastric sleeve surgery. Hiatal hernia is a defect in the opening in the breathing muscle through which the stomach herniates into the chest. Hiatal hernia repair restores normal anatomy by reducing the stomach back into the chest and closing the hernia defect. Keeping part of the stomach in the chest especially after sleeve gastrectomy results in severe acid reflux. Gastric sleeve has low compliance and readily responds to negative chest pressure. Negative pressure transmitted into gastric lumen results in a plunger like effect: acid and bile are aspirated into the upper part of the sleeve and distal esophagus where there is negative pressure. The effect is reproduced with the smallest hiatal hernias necessitating repair of any size hiatal hernia during sleeve gastrectomy. Since acid reflux and hiatal hernias are prevalent in the obese patient population careful testing for hiatal hernias prior to gastric sleeve surgery is routinely performed at Houston Weight Loss Surgery Center. Testing is performed using upper endoscopy. Additional tests like ambulatory pH testing and esophageal manometry are added if needed. Using this approach, we have prevented new onset acid reflux after sleeve gastrectomy and cured pre-existing acid reflux with proper hiatal hernia repair and gastric sleeve surgery.

#### Single Incision Gastric Sleeve Surgery
I have recently evaluated a patient for severe heartburn and food regurgitation following gastric sleeve surgery performed in 2013 in Houston. The patient was happy with weight loss results. She had excellent restriction but suffered from severe GERD related symptoms poorly controlled with high dose proton pump inhibitors. An UGI study showed around 5 cm of upper sleeve herniating into the chest with significant narrowing at the level of the hiatal opening. The intra-abdominal sleeve lumen appeared narrow with obliteration of the incisura angularis. An upper endoscopy revealed ulcerative distal esophagitis, incarcerated hiatal hernia and a tight stricture at the level of the hiatal opening. I was not able to pass the endoscope through the stricture to examine the rest of the sleeve. I was not sure if the sleeve lumen itself was narrowed at the hiatal opening or the angulation and herniation of gastric sleeve at that level resulted in this tight stricture.
The decision was made to repair the hiatal hernia hernia and convert the narrowed gastric sleeve to gastric bypass to alleviate acid reflux. Surgery was scheduled but not yet performed. Upon reviewing the operative report, I noted that the gastric sleeve surgery was performed using SILS (Single incision laparoscopic surgery). SILS consists of placing a single port in the mid -abdomen through which a number of specialized instruments can be inserted to performed gastric sleeve surgery. The advantage of such an approach is to reduce the number of incisions and improve cosmesis. The major disadvantage of SILS is that it restricts instruments to in-line, parallel movements. It violates the important concept of triangulation in laparoscopic surgery and limit the safe application of complex laparoscopic surgery. In the case of gastric sleeve surgery, SILS approach prevents proper sleeve contouring and preservation of the incisura angularis. In this particular patient, SILS may have contributed to the formation of a narrow sleeve lumen with an obliterated incisura angularis, thus contributing to severe post sleeve acid reflux. Luckily the use of SILS in Houston for gastric sleeve surgery in particular is limited saving many patients unnecessary complications. At Houston Weight Loss Surgery Center, we advocate safe and effective laparoscopic surgery. we place 5 trocars in the abdominal wall to easily access the stomach from all sides to perform safe and effective gastric sleeve surgery. We preserve the incisura angularis to prevent acid reflux development after sleeve gastrectomy.

#### Single Incision Sleeve Gastrectomy
One of the most important surgical principles in gastric sleeve surgery is contouring the stapled stomach to prevent narrowing or twisting. To achieve this aim, I routinely place three 12 mm ports along the umbilical level to be able to staple from 3 different angles. Indeed, the first two firing of the linear staplers are always performed from the right lower quadrant port. Using this port, allows to stay away from the incisura angularis preventing narrowing at this critical location. The linear stapler is an articulating device. However, in many instances, even with sharp stapler angulation, firing from the midline port, risks narrowing the incisura angularis.

Single incision laparoscopic surgery, also known as SILS, limit the dissection and stapling along one single axis. Greater curvature mobilization in obese patients with large left hepatic lobe and thick omentum requires more than one working axis. Taking down the short gastric blood vessels without proper triangulation and adequate retraction by the assistant is quite cumbersome.

Despite these limitations, several studies have been published about single incision sleeve gastrectomy demonstrating safety and feasibility. A study published by Dagher el al. in 2016 in SOARD (Surgery for Obesity and related Diseases) journal evaluates 1000 consecutive single-port laparoscopic sleeve gastrectomy performed at one single hospital in Paris, France. The median BMI was 42.6 and only 7.8% of the patients required the addition of one extra port to complete the procedure. The staple line leak rate was 2.8% and the overall morbidity rate was 8.1%. incisional hernia from trocar insertion site was 3.7%. The authors conclude that gastric sleeve surgery can be routinely performed using SILS technique and the results are comparable to traditional mutli-port laparoscopic sleeve gastrectomy. It is hard to duplicate such results and very few bariatric surgeons in the US advocate the use of SILS for sleeve gastrectomy these days. Better cosmesis and decreased pain are desirable outcomes that we all seek. However, gastric sleeve surgery is primarily a contouring procedure that requires the use of more than one surgical axis. Limiting the gastric resection to one direction, along one single port, is not the optimal approach to creating the “perfect sleeve”. Therefore, in the absence of a modified stapling device that can be positioned along any desired axis of resection within the abdominal cavity, SILS remains a sub-optimal approach for sleeve gastrectomy.

#### Sleeve Gastrectomy and Increased Intra-Gastric Pressure
Does gastric sleeve surgery increase intra-gastric pressure? The short answer to this question is unknown. There are no studies I am aware of that compare the gastric pressure before and after gastric sleeve surgery. Furthermore, intra-gastric pressure varies greatly throughout the day and depends on several factors like gastric wall compliance, gastric volume and content, pyloric contractions…

Gastric fundus is the most compliant part of the stomach and is resected during sleeve gastrectomy. Consequently, it is possible that gastric wall compliance decreases after sleeve gastrectomy leading to increased intra-gastric pressure. However, gastric emptying also increases following gastric sleeve surgery and therefore the integrated intra-gastric pressure may not significantly increase.

The assumption of increased intra-gastric pressure was introduced by several bariatric surgeons trying to explain sleeve gastrectomy staple line leak rate at the angle of Hiss area. It was assumed that gastric sleeve surgery leads to increased intra-gastric pressure. Increased luminal pressure not only results in leak development but also it delays and sometimes prevents healing. Such assumptions, however, have never been proven. Narrowing at the incisura angularis may cause increased intra-gastric pressure leading to increased staple line leak rate. However, a wide incisura angularis is unlikely to be associated with increased intra-gastric pressure. Therefore, a well performed sleeve gastrectomy is most likely associated with normal intra-gastric pressure, lower staple line leak rate, and lower incidence acid reflux. Indeed, a well performed gastric sleeve surgery may be associated with decreased intra-gastric pressure. Studies are needed to evaluate intra-gastric pressure before and after sleeve gastrectomy. New tools need to be developed to study gastric wall compliance, gastric volume and intra-gastric pressure. A silicon covered electronic chip attached to the gastric mucosa may deliver such information over several days like a pH Bravo capsule.

#### Sleeve Gastrectomy for BMI less than 35: Is it Worth it?
“Determining the health benefits of sleeve gastrectomy in patients with body mass index, BMI less than 35” is a new article published in Surgery for Obesity and Related Diseases journal. The authors compare the outcomes of sleeve gastrectomy in 1073 patients with low BMI to 44511 patients with BMI more than 35 (mean BMI 46.7).

Statistical analysis shows comparable rates of hypertension, diabetes and hyperlipidemia medication discontinuation. Low-BMI patients were more likely to achieve a healthy BMI (less than 25). The authors conclude that despite being older and with higher rates of metabolic disease, low-BMI sleeve gastrectomy patients benefited from bariatric surgery. Furthermore, low-BMI sleeve gastrectomy patients were more likely to achieve a healthy weight. Therefore, abolishing the BMI threshold for sleeve gastrectomy should be considered.

I wholeheartedly agree with these conclusions. Sleeve gastrectomy is currently one of the safest general surgeries we perform with very high success rate. Why wait to lose weight? Bariatric surgery is currently the most effective treatment for type 2 diabetes. Denying low-BMI patients with metabolic disease a safe and effective procedure like sleeve gastrectomy is not reasonable. BMI is a statistical tool established more than 50 years ago by insurance companies to predict mortality in a population. BMI, however, is not a personalized measure of one’s health. A diabetic low-BMI patient is at higher risk for cardio-vascular disease then a non-diabetic high-BMI patient. Eliminating diabetes at a lower BMI and younger age should be the norm rather than the exception. Sleeve gastrectomy is a powerful tool to safely control and cure metabolic disease. It is time to update our guidelines.

#### Sleeve Gastrectomy in Patients with Previous Nissen fundoplication
I read with great interest the case series published this month in Surgery for Obesity and Related Diseases, SOARD, by Yerdel et al. “Sleeve Gastrectomy in patients with previous antireflux surgery. Preliminary results of the “no-touch to posterior wrap” technique. The authors converted 14 Nissen fundoplication patients with morbid obesity to sleeve gastrectomy. Mean follow up time was around 2 years after conversion surgery. Conversion surgery preserved the posterior and right lateral aspect of the wrap. The authors took down the left side of the wrap and stapled this part off along with the rest of the gastric body to complete the sleeve gastrectomy. The main advantage of such an approach is to decrease morbidity associated with complete wrap take down. Furthermore, the risk of creating septated pouch by stapling the left aspect of the wrap is practically eliminated adopting the described approach.

At Houston Weight Loss Surgery Center, we have safely performed a number of Nissen fundoplication revisions to sleeve gastrectomy.  I have preserved the wrap in most cases and performed gastric sleeve resection below the wrap. My approach consists of complete wrap mobilization along the left crus to be able to include a good part of the posterior aspect of the wrap in the resected gastric sleeve. In most cases, the posterior aspect of the Nissen fundoplication wrap was stretched and easily resected. We did not have any ischemia of remnant wrap. Weight loss results were good at one year with most patients losing more than 50% of their excess weight. Patients with recurrent hiatal hernia underwent redo hiatal hernia repair during Nissen to sleeve conversion surgery. Patients presenting with acid reflux symptoms underwent complete GERD work-up including ambulatory pH testing and esophageal manometry. Patients with slipped Nissen fundoplication or confirmed recurrent acid reflux underwent complete wrap take down and conversion to sleeve gastrectomy. At Houston Weight Loss Surgery Center, the incidence of de novo acid reflux or worsening existing acid reflux after sleeve gastrectomy is almost zero. Our approach of preserving the antrum, preventing narrowing of incisura angularis, and properly repairing any existing hiatal hernia has resulted in excellent acid reflux control. The only reason we preserve the wrap in sleeve gastrectomy conversion cases is to decrease morbidity and mortality. I agree with the author, the most difficult aspect of Nissen fundoplication take down is dissecting posterior wrap adhesion to posterior esophagus and crura. Anterior wrap mobilization is much easier and safer. Most importantly, it allows for safer stapling of redundant gastric fundus with very low risk of pouch septation.

 

#### Sleeve Gastrectomy Technique: Does It matter?
I read with interest the new study “Assessment of Sleeve Gastrectomy Surgical Technique: First Look at 30-Day Outcomes Based on the MBSAQIP Database” published by my colleague Dr. Chaar in JACS current issue. The author compares different techniques in staple line reinforcement in sleeve gastrectomy cases collected in the MBSAQIP database. A total of 81521 primary sleeve gastrectomies were retrospectively analyzed. The study primary outcomes were bleeding defined as any event requiring blood transfusion and staple line leak. The different techniques involving staple line reinforcement included the use of absorbable membranes like bovine pericardial strips to buttress the staple lines, staple line oversewing, or both buttressing and oversewing.
The authors conclude that sleeve gastrectomy leak rate is not affected by staple line reinforcement technique. On the other hand, the study shows that staple line buttressing with or without oversewing, but not oversewing alone, decrease postoperative bleeding.
At Houston Weight Loss Surgery Center, I routinely use staple line reinforcement using absorbable buttressing membranes to decrease postoperative bleeding. I avoid oversewing the staple line as it leads to staple line twisting and narrowing. I agree with study results that staple line reinforcement does not decrease leak rate. I strongly believe that narrowing the incisura angularis leads to partial obstruction. Gastric lumen obstruction at the incisura angularis increases intra-gastric pressure potentially contributing to staple line failure at the level of the angle of His. In order to preserve the natural angulation of the stomach at the incisura angularis, we avoid resecting the stomach in that area over a bougie. Rather, we fire the first two to three stapler loads without a bougie in place then insert a 40 F bougie and continue sleeve resection.

#### Sleeve Gastrectomy, GLP-1 Secretion and Gastric Emptying
A prospective study titled “The effect of sleeve gastrectomy on GLP-1 secretion and gastric emptying” has recently been published in SOARD (Surgery for Obesity and Related Disorders) journal. Sista el al demonstrate that gastric sleeve surgery results in significant increase in both gastric emptying rate and post-prandial GLP-1 secretion, 3 months after surgery for both solids and liquids.

The authors attribute the increased gastric emptying following sleeve gastrectomy to altered stomach functional anatomy and gastric fundus accommodation reflex. Furthermore, they show a strong linear correlation between percentage gastric retention rate and post-prandial GLP-1 blood levels. The authors conclude that accelerated gastric emptying following gastric sleeve surgery increases GLP-1 secretion by distal intestinal L cells most likely by increasing undigested nutrient transit across the small intestine. Chronic exposure to a high nutrient flux into the intestine enhances intestinal nutrient sensing leading to increased GLP-1 secretion.

Indeed, the central mechanism of action of metabolic and weight loss surgery is altering the interaction between ingested food and gastro-intestinal tract. Altered interaction results in the secretion of several neuro-endocrine signals like GLP-1 that results in weight loss, improved blood glucose levels, insulin secretion and insulin resistance…

Unfortunately, research in this field remains weak. Most bariatric related research and publications are still focused on the outdated concept of mechanical restriction. New procedures like gastric balloon and gastric plication (endoscopic or laparoscopic) are developed and offered as effective weight loss solutions.

Gastrointestinal motility research is vital in elucidating the mechanism of action of bariatric surgery. Gastroparesis, GERD, type 2 diabetes and obesity are different kinds of gastro-intestinal motility disorders. Unraveling the mechanisms of gastro-intestinal motility in health and disease will yield great solutions to these disorders that have reached epidemic levels.

#### Staple line Reinforcement, Distance From Antrum and Bougie Size: A New Study From MBSAQIP
A fascinating new study analyzed 190,000 gastric sleeve cases performed between 2012 and 2014 at accredited bariatric surgery centers by MBSAQIP (Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program). The study was presented at the 2016 annual meeting of the American Surgical Association. 80% of the 1634 surgeons who performed these gastric sleeve surgeries used staple line reinforcement. A practice associated with decreased bleeding but a significantly higher leak rate according to this analysis. The study does not expand on the type of reinforcement used. Therefore, one cannot conclude if all types of reinforcement are associated with increased leak rate. This may be a major weakness associated with this high power study as over-suturing the staple line with or without imbrication may narrow the incisura angle and weaken the staples increasing the leak rate. Reinforcement material like Seamguard and bovine pericardium is conceptually and mechanistically different from suturing the staple line. Hence, it would be very interesting to break down the staple line leak cases into types of reinforcement to further understand this serious complication and better prevent it in the future.

The analysis further demonstrates that contrary to previous recommendations, weight loss was greatest in gastric sleeve cases with a bougie size of 40 French or more and a preserved antrum. Indeed, weight loss increased incrementally as the distance from the pylorus increased from 4 to greater than 6 cm. In other words, avoiding stomach “mutilation” is a good practice associated with improved weight loss. Gastric sleeve surgery is a metabolic procedure. Weight loss and blood sugar improvement result from altering gastric motility and gastric emptying patterns. These physiologic alterations are most likely related to gastric fundus resection. Reducing the gastric sleeve volume by itself does not result in better weight loss. Weight loss is in fact not proportional to gastric sleeve volume reduction. As this study alludes to, weight loss is improved with antral preservation. One would conclude that the worst gastric sleeve is that which destroys the antrum by using a small bougie size and starting the resection very close to the pylorus. The antrum is the gastric pump and by preserving this vital part of the stomach gastric emptying is improved. In my opinion, the best gastric sleeve surgery is the one that completely resects the ballooning part of the stomach while preserving the gastric antrum. A better approach to gastric sleeve resection is gastric fundus invagination, GFI. GFI is a procedure I developed based on these concepts and observations. It prevents gastric fundus relaxation and meal accommodation leading to increased gastric emptying. GFI has the advantage of being reversible, safe (short staple line), and a non “mutilating” procedure. GFI preserves gastric fundus tissue that secretes Leptin a hormone that contributes to increased satiety and may lead to better long-term weight loss than gastric sleeve surgery. Additional studies are needed to elucidate the role of gastric Leptin in weight loss surgery and its effect on long-term weight loss. If Leptin is indeed associated with better or more balanced weight loss then GFI may be a better option than gastric sleeve resection.

#### Staying Hydrated in Houston Summer Heat
The climate in Houston is humid and subtropical. July and August are typically unbearable. This year, however, July was the hottest month ever since record keeping began a century ago. With soaring heat indices, water losses increase and staying hydrated becomes a challenge. The reason being that water homeostasis is not perfect and dehydration commonly occurs. By the time you are thirsty, you have lost around 1% of your body water and you are already dehydrated.

The American Journal of Clinical Nutrition has recently published a study titled “Minor degree of hypohydration adversely influences cognition: a mediator analysis”. 101 volunteers were subjected to a temperature of 30 degrees Celsius for 4 hours and randomly divided into two groups. The first group drank 300 ml of water during the study period and the second group did not consume any fluids. Episodic memory, focused attention, mood and the perceived difficulty of tasks were measured on 3 occasions. The authors found that drinking water improved cognitive function like memory and focused attention even with less than 1% body water loss. Thirst was associated with poorer memory and increased thirst was associated with a decline in subjective energy and increased anxiety and depression.

The value of this study is that hypohydration, or loosing less than 1% of body water, a common daily occurrence in Houston, affects cognitive functions. Hypohydration is particularly common among our bariatric patient population especially in the first few months after bariatric surgery. Hypohydration is a common cause of fatigue, poorer mood, anxiety and depression. At Houston Weight Loss Surgery Center, we strongly encourage our patients to sip on water continuously throughout the day especially in the immediate postoperative period. Do not wait until you feel thirsty to drink water especially in this hot and humid weather. If you recovering from gastric sleeve surgery avoid going outside for long periods of time. You may not be able to keep up with water losses and you may end up dehydrated very fast.

#### 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:

Stop Junk food consumption
Stop eating out
Completely empty your house from junk food snacks
Don’t skip breakfast
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 fat, sugar, 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.”

#### The Biggest Loser: Struggling To Keep Weight Off
The New York Times Magazine current issue discusses the weight loss struggles, contestants of NBC’s reality TV show “The Biggest Loser” have been facing after one year of intense dieting and exercise. Most participants of this show who lost most of their excess weight have gradually gained it back.

Researchers from the National Institute of Health followed these contestants in an attempt to analyze the effect of calorie reduction and daily exercise on weight loss. They have discovered fascinating new data about weight loss, metabolism and body weight regulation. We already know that resting metabolism decreases with weight loss. However, what researchers observed with the Biggest Loser contestants that as they regained lost weight, resting body metabolism did not increase. Instead, resting metabolism became slower as the pounds kept piling on. As if the brain is further maximizing the weight regain process and trying to get back to the initial starting weight as fast as possible.

6 years after weight loss, the body was still fighting for weight regain. The Biggest Loser contestants were on TV, had the most intensive program for weight loss by diet and exercise. Professional exercise physiologist and dietary experts closely monitored every participant in a supportive and encouraging environment. They lost the weight but struggled and failed to keep it off.

When it comes to maintaining weight loss using diet and exercise we are all losers. With gastric sleeve and gastric bypass, the metabolic set point is changed allowing for effective weight loss with no compensatory increase in hunger and appetite or decrease in resting metabolism. Operating on the stomach changes a number of neuro-hormonal signals that control appetite and metabolism. Many of these signals are still poorly understood. However, the concept for durable and effective weight loss has been established. Calorie restriction by itself is not a weight loss solution. Yet, the FDA has recently approved intra-gastric balloon technology. Hopeless attempts at justifying non-sense procedures for weight loss like gastric balloon are hard to swallow in light of our current understanding of obesity and weight loss. The gastric balloon market is struggling at least in Houston, TX. Physicians and patients are too knowledgeable and well informed to be fooled by ineffective weight loss approaches. Even, when used for cosmetic purposes it is hard to justify an $8,000 procedure to loose 15 pounds for 6 months.

From this humble platform, I would like to reach out to the health industry interested in developing a solution for obesity. Please concentrate your efforts on understanding how does bariatric surgery work and accordingly model your endoscopic devices. Don’t come up with devices, like the gastric balloon, that contradict established mainstream knowledge and mechanisms for durable weight loss. It is difficult and hard to crack the obesity enigma. However, it is worth every penny you invest because millions of lives are at stake.

#### The Case for Gastric Sleeve Surgery for Treatment of Diabetes
Sleeve surgery in Houston is the most commonly performed procedure for weight loss. Gastric sleeve surgery is, however, an excellent treatment option for type two diabetes without the long-term complications of gastric bypass. The underlying mechanism of diabetes resolution following gastric sleeve surgery is not fully elucidated. When properly performed, sleeve surgery, accelerates gastric emptying. The loss of the compliant gastric fundus with preservation of the antral pump lead to enhanced gastric emptying. The rapid food transit through the proximal gut changes the interaction between ingested food and intestinal tract leading to altered neuro-hormonal signals that seem to improve blood glucose level.

The short term evidence for gastric sleeve efficacy in type 2 diabetes resolution is robust. Many studies have demonstrated equal efficacy between gastric sleeve and bypass at 12 months after surgery. At 3 year follow up after surgery, the STAMPEDE trial showed that gastric bypass procedure is superior to sleeve surgery in terms of blood sugar control. Why are gastric sleeve surgery metabolic benefits less durable than those of gastric bypass when it comes to blood sugar control? Is it because of gastric fundus dilation and loss of the accelerated gastric emptying? Is there room for improving our current surgical technique to improve sleeve durability? Or is the sleeve doomed to fail in the long run?

I firmly believe that diabetes resolution following gastric sleeve surgery is highly dependent on how well the stomach is resected. A radical antrectomy, narrowed incisura and retained gastric fundus will greatly diminish the successful long term outcome of gastric sleeve surgery. “Contouring the sleeve” is not as simple as it sounds. I have learned over the past few years that complete gastric fundus resection requires complete gastro-esophageal junction mobilization and not simple visualization of the left crus. The fat pad must be carefully elevated and the angle of Hiss clearly visualized prior to gastric fundus resection. I always leave a small dog ear in that area to decrease the incidence of staple line leak. However, a retained posterior fundus will most likely dilate with time leading to GERD, weight regain and diabetes recurrence. Additionally, a narrowed incisura angularis creates a partial obstruction that leads to increased intra-gastric pressure and abnormal gastric peristalsis. Consequently, staple line leak, GERD and gastric fundus dilation incidence increases. A dilated gastric fundus in the setting of a narrow angularis results in decreased gastric emptying. If type 2 diabetes is a gastro-duodenal motility disorder, then one can easily see how gastric fundus dilation over time diminishes the effectiveness of gastric sleeve surgery in terms of blood sugar control.

It is very important to mention that gastric sleeve surgery “contouring” has nothing to do with bougie size. Indeed, bougie placement distorts the gastric angle at the incisura and prevents proper resection. For this reason, I navigate the incisura angularis without a bougie in place. Only after 2 or 3 staple firing that I place the bougie and continue the sleeve resection creating a straight gastric sleeve tube with no twisting or narrowing. When I perform the upper endoscopy intra-operatively I can visualize the antrum through the newly created angularis from the gastro-esophageal junction. If you have to maneuver the scope to pass through the angularis into the antrum you have narrowed the angularis and you have most likely increased the patient chances for long term failure.

From this perspective, one can appreciate the difference between gastric bypass and sleeve surgery from a technical point of view. There is little variation in gastric bypass anatomy that can affect its metabolic outcome. Gastric pouch size has no effect on extent of post-operative weight loss or diabetes resolution. Conversely, gastric fundus size in a sleeve gastrectomy can greatly alter the metabolic outcome especially in the long term. Long-term studies are needed to further understand the durability of gastric sleeve surgery in the treatment of type 2 diabetes. Particularly important, are studies that evaluate gastric emptying and gastric fundus size, several years after surgery, and their effect on blood sugar control.

#### The Clues to the Causative Etiologies of Type 2 Diabetes
The current issue of Surgery for Obesity and Related Diseases is entirely dedicated to the widespread problem of Diabetes. There are 422 million diabetics in the world making Diabetes one of the epidemic diseases of our time. Traditionally, type 2 Diabetes has always been considered a medical problem. Diabetes, however, is most likely a surgical disease. The common association between obesity and type 2 diabetes has long been established. It has been accepted that obesity leads to peripheral insulin resistance which causes a rise in blood glucose levels. This in turns elicits increased insulin secretion. As insulin resistance worsens, hyperglycemia further stimulates insulin secretion leading eventually to pancreatic islet cells burnout and overt diabetes.

The advent of bariatric and metabolic surgery has challenged this causative theory. Dr. Walter Pories was first to publish in 1995 a study on the immediate normalization of blood glucose level within 24 hours of gastric bypass surgery prior to any significant weight loss. Numerous publications followed this initial landmark study and demonstrated that the manipulation of the gastro-intestinal tract results in altered neuro-hormonal signals that improve blood sugar control independent of weight loss. The amelioration of diabetes following metabolic surgery like gastric bypass and sleeve gastrectomy was dramatic when compared to current medical treatment protocol. The exact mechanisms for diabetes resolution and sometimes cure following weight loss surgery are still not fully understood. However, the theoretical framework for diabetes development has been set. Peripheral insulin resistance, due to fat accumulation in muscle and adipose tissue, is less likely to be the cause of type 2 diabetes. Rather, insulin resistance is a consequence of type 2 diabetes. It has long been established that insulin is secreted into the portal system in a pulsatile fashion. Loss of this pulsatile insulin secretion is the first step in type 2 diabetes development. Indeed, many studies have shown that patients with pre-diabetes or increased glucose intolerance have lost their pulsatile insulin secretion. The loss of this delicate mechanism slowly results in increased central and peripheral insulin resistance which in turn exacerbates hyperglycemia. Hyperglycemia further stimulates insulin secretion leading eventually to islet cell fatigue and burnout. Manipulation of the gastro-intestinal tract in the form of gastric bypass or sleeve surgery seems to break this vicious circle leading to restoration of islet cell pulsatile insulin secretion. Today, there are no studies on the pulsatile insulin secretion following gastric bypass surgery or sleeve gastrectomy that I am aware of. Such studies, however, are crucial to improving our understanding of type 2 diabetes development and treatment.

In conclusion, surgical manipulation of the gastrointestinal tract leads to altered gut motility and neuro-hormonal secretion. These changes have dramatic effect on several organs in the body including the pancreas. Studying the pulsatile insulin secretion of pancreatic islet cells following weight loss surgery may help uncover a potential causative etiology of type 2 diabetes.

#### The Dumbbell Gastric Sleeve: A Recipe for Heartburn
A 45-year-old female patient presented herself to my weight loss surgery clinic with severe heartburn and food regurgitation of two-year duration. She underwent sleeve gastrectomy 7 years ago by a bariatric surgeon in Houston who is no longer in practice. Patient did well initially and lost around 100 pounds. However, over the past 4 years she started experiencing acid reflux symptoms. Her acid reflux was initially managed with medications and lifestyle changes. However, over the past two years GERD symptoms have gotten worse and difficult to control even with high dose proton pump inhibitors. Patient reports excellent restriction and good appetite control. She still maintains her 100-pound weight loss.

Upper endoscopy, performed in Houston by a general gastroenterologist with limited experience in bariatric surgery, showed moderate gastritis and distal esophagitis. No description of hiatal hernia, sleeve shape, gastric fundus size, incisura diameter mentioned. I performed an UGI that showed a dumbbell shape gastric sleeve with significant narrowing at the level of the incisura angularis and gastric body. Gastric fundus was dilated and appeared like a perfect circle with air fluid level on the X-ray pictures. Contrast emptying from stomach into duodenum appeared to be accelerated but there was contrast pooling in the gastric fundus. I repeated the upper endoscopy to confirm upper GI findings and demonstrate significant laxity at the diaphragmatic opening. There was also narrowing and twisting at the level of the incisura angularis creating a functional obstruction.

Aggressive gastric sleeve resection over a small bougie size results in a narrowed incisura angularis. A narrowed incisura angularis leads to functional gastric sleeve obstruction; as a result, gastric fundus, cardia and hiatal opening dilate over time. This slowly leads to hiatal hernia formation and a dumbbell looking gastric sleeve. A dilated gastric fundus in the setting of a hiatal hernia results in severe heartburn and food regurgitation. Treatment requires surgical correction of hiatal hernia and conversion of gastric sleeve to gastric bypass. Gastric bypass alleviates the functional obstruction at the level of the incisura. In certain cases, adhesion formation around the incisura angularis form and narrow this area. Scar tissue resection at this level alleviates the obstruction. The associated hiatal hernia still needs to be repaired to control acid reflux symptoms. The dilated gastric fundus is either resected or plicated around the distal esophagus.

#### The Effect of Dietary Fat on the Hypothalamus
I read with great interest the recent study by Valdearcos et al titled “Microglial Inflammatory Signaling Orchestrates the Hypothalamic Immune Response to Dietary Excess and Mediates Obesity Susceptibility” and published in the journal of Cell Metabolism. The authors neatly demonstrate that hypothalamic microglia rapidly increase in response to high fat diet in a mouse model. Increased microglia result in increased inflammation in the hypothalamus and neuronal stress. This is turn leads to reduced sensitivity to homeostatic signals like leptin leading to over-consumption and weight gain. This study represents the first evidence linking dietary over-consumption and hypothalamic dysfunction leading to fat accumulation. Center to hypothalamic dysfunction is increased inflammation caused by increased microglia. Microglia are macrophage cells and are the first and main immune defense in the brain. They typically respond to infections but in the case of obesity they respond to excess dietary fat.

It is quite refreshing to read such studies that demonstrate the role of the hypothalamus in energy metabolism and obesity. The hypothalamus regulates body weight the same it controls body temperature. Unless the set point for body weight is altered weight gain, or loss cannot occur. Increased inflammation mediated by the immune system in response to increased fat consumption seems to alter the hypothalamic set point for body weight. Excessive food consumption or consumption of certain types of nutrients like saturated fats causes immune system over-activation. This in turn leads to chronic inflammation. Valdearcos et al nicely show that chronic inflammation in the hypothalamus reduces its ability to respond to leptin leading to obesity. Hundreds of neuro-hormonal signals convey messages to the hypothalamus from peripheral organs like the gastro-intestinal tract, pancreas, liver and adipose tissue. The hypothalamus integrates these messages to maintain a stable body weight. It would be interesting to study the effect of sleeve gastrectomy and gastric bypass surgery on hypothalamic inflammation. Weight loss surgery resets the hypothalamic set point for body weight. Does weight loss surgery decrease hypothalamic microglia and associated inflammation? We know that GLP-1 and PYY increase after weight loss surgery. It is possible for such an increase to overcome the hypothalamic resistance to respond to such signals. With decreased calorie intake and increased hypothalamic response to gut signals, weight loss surgery achieves durable and significant weight loss. Calorie restriction by itself, without restoring the hypothalamic set point of body weight, is not likely to resolve the underlying pathophysiology of obesity.

#### The Elipse Balloon: A new gastric Balloon with Interesting Features
“The Elipse Balloon, a swallowable gastric balloon for weight loss not requiring sedation, anesthesia or endoscopy: a pilot study with 12 month outcomes” a new article published in the current SOARD issue by Dr. Raftopoulos.Dr. Raftopoulos receives consulting fees from Allurion technologies. Allurion technologies, Natick, MA, USA is the developer company of Elipse Balloon. The study is a prospective, nonrandomized and observational analysis of 12 enrolled patients. Elipse Balloon is folded in a vegetarian capsule and attached to a thin catheter via a self-sealing valve. Patients swallow the capsule; an X-ray study confirms position in the stomach before filling the balloon with 550 ml of water. The catheter is disconnected from the balloon by pulling it out. A bio-absorbable film covers the valve and degrades slowly over a 4-month period. Once degraded, the valve is exposed and the balloon empties spontaneously. It is then expected to pass through the pylorus into the intestines and then naturally excreted. In this study, 3 patients vomited the balloon and the rest excreted it in stool with no complications. The authors recommend soft diet and antiemetic towards the end of the treatment to prevent balloon emesis.

As with previous balloon studies the authors find excellent weight loss comparable to other balloon devices on the market like Obalon, Orbera and Reshape. They caution us, however, on “substantial weight regain” if balloon patients “do not take advantage of balloon therapy and transition to a permanent healthier lifestyle”. The authors further add: “these new technologies should be embraced in the context of long-term exercise, diet and behavior modification protocol that will maximize long-term weight maintenance. A balance between practice growth potential by the introduction of these technologies and a commitment to long-term quality care and patient education must be struck to achieve this goal”.

Unfortunately, we continue to read the same wrong rhetoric about diet and exercise to maintain weight loss. Diet and exercise are ineffective in maintaining weight loss unless the underlying metabolic abnormality has been addressed. Gastric balloon, a purely restrictive procedure, unlike sleeve gastrectomy and gastric bypass surgery, does not alter metabolism. Therefore, balloon induced starvation over a 4-month period is unlikely to result in permanent weight loss despite adhering to a healthy lifestyle. This basic metabolic and weight loss concept has been clearly established. The working hypothesis for weight loss surgery is clear. We need to properly use this knowledge to develop new effective weight loss technology rather than ineffective but minimally invasive techniques that are only effective in misleading obese patients struggling to lose weight.

#### The FDA Approves A New Device For Weight Loss: Reshape Dual Balloon
The U.S. Food and Drug Administration (FDA) has just approved a new device for weight loss called the Reshape Dual Balloon. The procedure is indicated for patients with BMI ranging between 30 and 40. The balloon is placed in the stomach through the mouth using endoscopy. The balloon is inflated in the stomach thereby preventing the patient from eating large meals. It is thought that the balloon increases satiety and controls appetite thus leading to weight loss. The balloon must be removed 6 months after insertion. Otherwise, the balloon may rupture inside the stomach and pass into the intestines causing obstruction.
A randomized study of 326 patients showed 14.3 pound average weight loss in those who received the balloon versus 7.2 pounds in the control group. After balloon removal, patients gained weight. An average of 4.4 pounds over 6 months following balloon retrieval. The study did not extend beyond one year.
The American Society for Metabolic and Bariatric Surgery (ASMBS) is very pleased with the approval because “the ReShape Dual Balloon offers a bridge between medications and surgery similar to a cardiac stent in cardiac disease.”
I am not sure what the ASMBS statement really means and why would the society be pleased with such a device. The weight loss is transient and small. Obesity is a chronic disease that results from disrupted interaction between the gastrointestinal tract and ingested food. Consequently, the digestive process including gastrointestinal motility, nutrient absorption, neuro-hormonal gastrointestinal signals and other substances secreted by the digestive system like bile are not properly functioning. We barely understand this complex physiology, and in the face of the obesity epidemic we come up with “silly” devices like bands and balloons as weight loss solutions and “bridges to nowhere.”
Personally, I would recommend the balloon as a temporary cosmetic procedure for an individual interested in loosing a few pounds before a wedding or a trip to the beach. ReShape Dual Balloon is not a weight loss procedure by any stretch of the imagination. Let us stay honest and stop marketing the device as “weight loss surgery without the surgery.”

#### The Gastric Fundus and Lap Band Removal
Last week I published a blog about acid reflux developing after gastric sleeve surgery in the setting of a hiatal hernia. Subsequently, I have received several questions from a number of followers and readers about acid reflux developing after Lap Band conversion to sleeve surgery. This is a very important topic especially that these days we are experiencing a high rate of band removal and conversion to other weight loss procedure for either worsening acid reflux related symptoms or failure to lose weight.

Lap band conversion to gastric sleeve surgery is a tricky surgery and ought to be approached with extra care in order to avoid unnecessary complications. Most of the questions I have received were related to worsening acid reflux following lap band conversion to sleeve. In particular, does a retained gastric fundus cause acid reflux following band conversion to sleeve. The short answer is yes. There are many reasons for GERD to worsen or develop de novo when converting a band procedure to gastric sleeve. Let’s explore them one by one.

First, almost all lap band patients have some degree of esophageal dysmotility secondary to years of band restriction or over-restriction. It is not normal to impede the free flow of food from the esophagus into the stomach. Placing a barrier in this high compliance, low resistance area forces the esophagus to work harder to transfer food into the stomach. The end result is a wide spectrum of esophageal dysmotility patterns ranging from low wave contractile amplitude to a full blown pseudo-achalasia condition. The esophagus, cardia and hiatal opening dilate in response to long-term band restriction. A hiatal hernia may develop and tertiary esophageal contractions are almost invariably noted on contrast studies. All these physiologic changes contribute to acid reflux disease. Adding a poorly constructed gastric sleeve (large retained gastric fundus, twisted sleeve lumen and/or narrowing at the incisura angularis) further exacerbates the underlying acid reflux problem. Particularly relevant to lap band conversion to gastric sleeve is the incompletely resected gastric fundus. Due to thick fibrotic tissue developing around the upper gastric fundus, a proper gastric fundus mobilization and resection may sometimes be difficult if not impossible. I personally stage all my lap band conversion to gastric sleeve for two reasons. First, almost all studies on this subject have demonstrated a lower leak rate by staging the conversion. Second, by allowing the scar tissue to remodel following band removal, gastric fundus dissection and resection is more adequate. Part of the gastric fundus is contracted and has retracted due to scar tissue development. Leaving part of the gastric fundus un-resected in the setting of a dilated hiatus and poor esophageal function and super-imposing the high pressure system associated with gastric sleeve surgery is a recipe for GERD.

For all these reasons, converting a lap band to gastric sleeve should only be done after careful consideration. My approach is as follows:

 	I decompress the band from all fluid content
 	I perform a baseline UGI to check for esophageal dilation, tertiary contractions, hiatal hernia
 	I perform an esophageal manometry for any patient suffering from persistent dysphagia or GERD related symptoms after band decompression
 	I repeat the UGI in 8 weeks and document resolution of esophageal dilation
 	Any patient with persistent esophageal dilation undergoes an esophageal manometry to assess esophageal motility
 	Lap band conversion to sleeve is offered only if esophageal motility is within normal
 	Lap band conversion to sleeve is staged and hiatal hernia repair is added if needed
 	Patients with persistent esophageal dilation, dysmotility, or GERD related symptoms are offered lap band conversion to gastric bypass. I have had great success in GERD related symptom improvement with gastric bypass. The Roux limb creates a negative pressure system that promotes esophageal emptying and prevents food regurgitation and reflux.

Patients who have undergone lap band conversion to gastric sleeve and are experiencing acid reflux symptoms ought to be thoroughly re-evaluated. Gastric sleeve surgery can be easily revised into gastric bypass with very high success rate and minimal morbidity and mortality in properly selected cases. If you are a bariatric patient and suffers from heartburn, food regurgitation, nighttime cough or difficulty swallowing give us a call. We offer comprehensive acid reflux testing in a center of excellence for obesity and acid reflux management.

#### The GLP-1 Debate
Glucagon-like peptide-1, GLP-1, is the most studied gut hormone. It promotes weight loss, increases satiety and stimulates insulin secretion while blocking glucagon release. Gastric bypass surgery and gastric sleeve procedure result in significant post-prandial increase in GLP-1. As a result, GLP-1 has been strongly suspected as a key mediator in metabolic surgery especially when it comes to the immediate post-operative diabetes resolution. Several studies in human and animal models have attempted to elucidate the role of GLP-1 in diabetes resolution and remission following bariatric surgery. One of the most interesting experiments were conducted in human gastric bypass subjects. A feeding tube was placed in the gastric remnant and a meal challenge test was conducted. One meal given through the oral route on one day and the same meal given through the feeding tube route on the second day. The difference in insulin, GLP-1 and glucose response was striking; gastric bypass changes the interaction between ingested meal and gastrointestinal system resulting in GLP-1 rise and lower post-prandial glucose levels. Researchers, however, have not been able to firmly establish a cause effect relationship between GLP-1 rise and the metabolic effects of bariatric surgery.

Jorgensen et al demonstrated in diabetic patients who underwent gastric bypass surgery that GLP-1 is essential to insulin function improvement and blood glucose normalization after surgery. The authors blocked the GLP-1 receptor using a high dose of Exendin 9-39 infusion and found that all the postoperative improvements of gastric bypass surgery were abolished by GLP-1 antagonist. Their study was published in Diabetes journal in 2013. It clearly demonstrated a cause effect relationship between GLP-1 and diabetes resolution. Other groups have also blocked the GLP-1 receptor in both human and animal models but found persistent improvement in post-prandial blood glucose level following metabolic surgery. Similarly, animal models with GLP-1 gene knockout show the same degree of diabetes resolution and weight loss following gastric bypass surgery as controls.

There is no doubt that multiple neuro-endocrine pathways between the gut and other organs like the brain, liver and pancreas are involved in mediating the metabolic effects of bariatric surgery. GLP-1 represents one of these pathways. Blocking GLP-1 receptors or using GLP-1 agonists by themselves is unlikely to duplicate the complex metabolic effects of gastric sleeve or gastric bypass surgery. However, GLP-1 is an important marker of gut changes following metabolic surgery. Lap band, gastric balloon, gastric plication, endoscopic sleeve gastroplasty and other purely restrictive procedures have not been found to be associated with any GLP-1 changes. Therefore, it is safe to assume that GLP-1 is a central metabolic marker and novel weight loss procedures that do not alter GLP-1 secretion are less likely to be associated with significant metabolic changes leading to durable weight loss and diabetes resolution or improvement.

A weight loss procedure that does not alter blood Ghrelin level nor increase gastric emptying and post-prandial GLP-1 levels is unlikely to result in durable and significant weight loss. Should we be early adopters of new bariatric treatments that rely on purely restrictive mechanisms of action? The answer is clearly NO. Instead, we ought to investigate and better understand bariatric surgery mechanism of action and accordingly develop endoscopic procedures. It is no longer accepted to develop a weight loss procedure based on mechanical restriction and expect weight loss surgeons to adopt it.

#### The Hairpin Sleeve Gastrectomy
The incisura angularis is the Achilles heel of sleeve gastrectomy. Preserving this natural gastric angulation is crucial to ensure proper weight loss while preserving basic gastric anatomy and function. Stapling too close to the incisura angularis results in sharp angulation in that area that causes functional obstruction. Functional obstruction of the gastric sleeve lumen increases the risk of postoperative staple line leak, decreases weight loss and precipitates acid reflux.

Chronic functional obstruction of gastric sleeve lumen results in increased intra-gastric pressure and proximal lumen dilation. The upper part of the sleeve enlarges with time leading to the creation of a neo-fundus. The upper part of the sleeve is more prone to dilation due to its thin and compliant wall. Furthermore, a small dog ear is typically left to decrease leak rate. This small residual gastric fundus has a larger diameter than the rest of the gastric sleeve lumen. The larger the lumen diameter, the higher is wall tension leading to more stretching and dilation. Indeed, the presence of a neo-fundus as the attached UGI picture depicts is an indirect sign of functional obstruction. Chronic obstruction also results in anterior and medial rotation of the gastric sleeve proximal to the incisura angularis resulting in the classic hairpin deformity and further accentuating the sharp angulation and obstruction.

Patients typically present with worsening acid reflux related symptoms poorly controlled with proton pump inhibitors. The combination of poor gastric motility, high gastric pressure and gastric fluid secretion accumulation in the neo-fundus results in severe reflux into the esophagus. The only effective solution in this case is to convert the gastric sleeve into a Roux-en-Y gastric bypass. The conversion is straightforward, effective and safe. Gastric bypass restores normal gastrointestinal motility. It immediately relieves all GERD related symptoms and promotes weight loss.

In summary, avoiding narrowing at the incisura angularis cannot be over-emphasized. Sleeve gastrectomy is a mutilating procedure but preserving basic gastric anatomy and function is mandatory to avoid complications. Gastric fundus invagination, a weight loss procedure that I have developed few years ago has the advantage of preserving gastric structure while modifying gastric emptying, and food interaction. Gastric fundus invagination or sleeve gastrotomy as Dr. Mason would like to call it has the potential of becoming the first line treatment for morbid obesity.

#### The Harmful Effects of Sugar
Halloween was just passed and most of us will indulge in large amounts of sugary treats. Indeed, Americans spend $2.1 billion on Halloween candy treats according to the National retail Federation. The world health organization has linked sugar consumption to many chronic diseases including obesity, diabetes and cancer. In the context of a sedentary lifestyle, excess sugar intake leads to detrimental metabolic effects. Glucose, a simple sugar, is an essential part of almost every living cell. It is the fuel that energizes our metabolic machinery. For this reason, glucose blood levels are tightly regulated. Low glucose levels arrests cell functioning and high levels are toxic. Insulin is the main hormone that controls blood sugar level. Secreted by pancreatic Beta cells, Insulin leads to increased glucose uptake by liver, adipose and muscle cells. These cells deposit excess sugar in the form of fat. Over time, and with continued increased sugar consumption, (American consume 11 million tons of sugar per year) and with minimal physical activity, fat deposition increases leading to insulin resistance. The pancreas responds by secreting more insulin leading to more fat deposition and insulin resistance. This vicious circle eventually leads to pancreatic beta cell failure and the development of type 2 diabetes. Persistently elevated blood sugar levels characterize type 2 diabetes. In Houston, diabetes has reached an epidemic level affecting a large portion of our society.
Fructose is another type of simple sugar. Fructose is commonly added in the form of high fructose corn syrup to more than 90% of processed food items sold in American groceries. The liver almost exclusively metabolizes fructose. As a result, elevated fructose consumption leads to fat deposition in liver cells and increased insulin resistance. Indeed, rats maintained on a high fructose diet develop obesity, type 2 diabetes and heart disease in a very short amount of time.
Sugar is not only toxic. It is very addictive. Sugar intake stimulates the reward centers in the brain in a similar manner as drugs like cocaine. Interestingly, the rewarding effect is blunted in obese and diabetic people leading them to consume more sugar to have the same effect.
Take home message: Excess sugar consumption in the form of candies, drinks, and processed food… is detrimental to your health. If you consider yourself as someone who has a sweet tooth, you may be addicted to sugar. Be aware of how much sugar you are consuming and take control of your eating habits. Otherwise, you are putting yourself at risk for developing insulin resistance. Try fruits instead of candies. Fruits contain fiber, minerals and vitamins and much less sugar than man-made sweets. Eliminate all forms of sugar from your house. Most importantly, leave the couch and join a gym or hit the trail. Daily activity helps burn excess calories and tone your muscles leading to lower insulin demand. If you have diabetes or suffer from obesity, diet and exercise alone may not be enough to improve your health. Consider gastric sleeve or gastric bypass surgery as an effective and durable treatment to your metabolic disorder.

#### The Ketogenic Diet for Obesity and Diabetes
An interesting report on keto diet for treatment of obesity and diabetes was recently published in JAMA, journal of the American Medical Association. The article is titled “The Ketogenic diet for obesity and diabetes – Enthusiasm outpaces evidence” by McMacken el al. The authors report that keto diet has received much attention lately mostly because low fat diets have failed to control the obesity and type 2 diabetes epidemics that plague our society. A meta-analysis of 13 studies with longer than one-year follow-up showed slightly better weight loss with keto diet when compared to high-carb, low fat diets. However, a meta-analysis of 32 studies found greater fat loss and higher energy expenditure with low fat diets when compared to keto diet. The authors further add that there are no studies evaluating the effect of keto diet on cardiovascular disease and overall mortality rate. Keto diet may improve HDL levels, but historical evidence shows no reduction in cardiovascular events with increased HDL levels. Similarly, the authors express doubt about the effect of keto diet on diabetes improvement. Long-term randomized studies comparing keto to low fat diet showed no difference in glycemic control among patients with type 2 diabetes.

The authors continue to add a number of side effects associated with keto diet including keto flu, nephrolithiasis, constipation, low fiber intake…Interestingly, the Inuit people surviving on a high fat diet in the North pole have a genetic mutation to reduce ketone body formation possibly conferring a survival advantage. The authors conclude that despite the popularity of keto diet physicians and patients need to cautiously appraise the evidence and further studies are needed to establish the safety or lack thereof of keto diet.

I fully agree with the authors that a plant-based diet based on legumes, full grains, fruits …is a healthy diet associated with decreased mortality and cardiovascular events. However, are obese and diabetic patients able to process a plant based, high carbohydrate diet to reap those health benefits. In the setting of insulin resistance and obesity, is a low carbohydrate diet like keto diet a better alternative? The best solution for obesity and type 2 diabetes is weight loss surgery like sleeve gastrectomy. Bariatric surgery changes the interaction between consumed food and gastrointestinal system resulting in neurohormonal changes that revers insulin resistance, improve appetite control… Short of a weight loss procedure like sleeve gastrectomy, asking an obese patient with a BMI of 50 to eat fruits, vegetables and grains and expect weight loss and better glycemic control is unrealistic. Obesity is a pathophysiologic state that prevents the body from normally processing carbohydrates. The alternative is to replace carbohydrates with a different form of energy like fat. Long-term fat consumption may not be healthy for you but so is obesity. Currently, there are no alternative diets to keto diet, for weight loss, in morbidly obese individuals. I fully agree with the authors that studies are needed to better understand the long-term effects of ketosis on cardiovascular mortality and events. Most importantly, I call for the complete elimination of processed carbohydrates and food from our modern diet to avoid damage to our body ability to process carbohydrate and prevent the development of insulin resistance and obesity.

#### The Key to Health and Longevity: An Anti-Inflammatory Diet
Inflammation is a crucial part of normal physiology. Inflammation allows cells to heal and fight microbes. It is a complex process that starts with an inciting agent like injury, a microbe or diet. Hundreds of signals lead to acute inflammation and cellular destruction leading eventually to elimination of the inciting agent. This is typically followed by an anti-inflammatory resolution response resulting in cellular rejuvenation and healing. Chronic inflammation occurs when there is no resolution of the initial inflammatory reaction. The immune system is chronically activated at a sub-clinical level below the perception of pain and development of fever leading to cellular damage and the development of chronic diseases like obesity, diabetes and cancer.

Diet plays an important role in cellular inflammation. Omega-3 fatty acids and many antioxidants like polyphenols decrease inflammation. Saturated fats, omega-6 fatty acids and refined carbohydrates, on the other hand, increase inflammation. Linoleic acid, a poly-unsaturated omega-6 fatty acids is metabolized to arachidonic acid which in turn leads to the formation of several leukotrienes and prostaglandins. The latter are pro-inflammatory eicosanoids that, when left unchecked, result in chronic inflammation and cell damage. Linoleic acid is present in processed vegetable oil made from corn, sunflower, and safflower. Vegetable oil has found its way to almost every processed food item you encounter on your grocery store shelves. Interestingly, insulin promotes the conversion of linoleic acid to arachidonic acid. Insulin is increased by excessive refined carbohydrate consumption like white flour and sugar. These high glycemic food items constitute a large portion of our modern diet. A doughnut for example is a mixture of saturated fats, linoleic acid and refined carbohydrates and the perfect recipe to induce inflammation in the body. A doughnut increases insulin levels due to its high content of white sugar and flour. Insulin then promotes the conversion of linoleic acid (the oil used to fry the doughnut) to arachidonic acid which in turn promotes inflammation. Sardines on the other hand are rich in omega-3 fatty acids, and low in saturated fat and cholesterol. Sardines do not contain any refined carbohydrates and are rich in vitamins and minerals. Sardines are therefore the perfect example of a food item that you ought to incorporate in your diet to prevent obesity, diabetes and cancer. Multiple studies have shown that a Mediterranean diet rich in olive oil, fish, and nuts while low on red meats and refined carbohydrates is one of the healthiest diet to follow. People around the world who follow this kind of a diet live longer and healthier.

J Prescott et al published a study in 2014 in the British Medical Journal on the effect of the Mediterranean diet on Telomere length. 121700 subjects have been followed since 1976. Individuals with greater adherence to Mediterranean diet had longer telomeres. An anti-inflammatory diet like the Mediterranean diet is indeed associated with a lower rate of telomere shortening leading to healthier cells and increased longevity.

In this holiday season, whether you are trying to prevent weight gain or lose weight for the new year, try to tip the balance in your daily eating habits towards an anti-inflammatory diet. Detox your body by avoiding the refined carbohydrates and oils that plague our modern food supply. Replace red meat and processed vegetable oil with fish and extra virgin olive oil. Replace dairy products like cheese and butter with nuts like walnuts and almonds. Finally avoid sugar and white flour consumption to prevent increasing insulin blood levels leading to increased inflammation and fat accumulation.

#### The Modern Bariatric Surgeon
You are overweight. You have diabetes and your blood sugar is poorly controlled. You have a ravenous appetite and pounds keep accumulating despite your best efforts. You live in Houston, the fourth largest city in America, where the biggest medical center in the world has been established, and you are wondering who can help you. Where can you find reliable, ethical, honest, safe, state of the art solution to your obesity problem? Your co-worker had gastric bypass surgery 10 years ago and your neighbor has just had a gastric sleeve. Both are happy with their decisions. Your co-worker has lost a total of 90 pounds and her hypertension and sleep apnea have completely resolved. You are visiting with your neighbor and he is telling you that gastric sleeve surgery is the best and safest option for you. Your PCP however, has a different opinion. You asked for her opinion and she thinks that gastric balloon or maybe a lap band is a safer option for you. Indeed, gastric balloon is non-surgical and fully reversible. You go online and google gastric balloon in Houston and find out that endoscopic sleeve gastroplasty is actually a better option than gastric balloon. This new and exciting procedure is similar to a traditional gastric sleeve but without all the cutting. Next day, as you are having your morning coffee, and thinking about your weight loss options, a TV interview on your local channel attracts your attention. A local bariatric surgeon in your area has just finished training on this exciting new procedure and is offering the procedure at a discounted rate. Most importantly, you find out that the sleeve gastrolasty is performed through the mouth and is reversible and does not burn any bridges in case you wish to convert it to a more traditional procedure like gastric sleeve or bypass. How cool is that?

You decide to further investigate the matter. While at work, you google sleeve gastroplasty and you read more about this procedure. You learn that several studies have been performed with promising weight loss results. Around 40 pounds are lost in the first 6 months after surgery. You pick up the phone and call your PCP asking for referral. Your PCP sends you to a bariatric surgeon she trusts and with whom she has had a good working relationship. You call the bariatric surgeon office to schedule an appointment but you are shocked to find out that sleeve gastroplasty is not a procedure they offer. Determined to find help, you go back to google search to look for surgeons who perform sleeve gastroplasty in the Houston area. As you are conducting your search you come across my blog and you read the following:

The modern bariatric surgeon is constantly bombarded by newer weight loss procedures. Making a decision, however, on which procedure to adopt shouldn’t be difficult. Any weight loss procedure that does not alter the neuro-hormonal system that controls weight, metabolism and hunger is not likely to result in permanent weight loss. More specifically, any bariatric procedure that is purely restrictive like gastric balloon, gastric plication, endoscopic sleeve gastroplasty and the notorious lap band is most likely going to fail. Ghrelin, GLP-1, PYY and other hormones are well-established markers for success after bariatric procedures. Human trials that omit studying these easily measured blood hormones are to be considered weak and unreliable studies. Furthermore, novel weight loss procedures that do not promote gastric emptying are also less likely to result in durable weight loss. Accelerated gastro-intestinal motility is a common feature to all effective weight loss procedures like gastric sleeve and gastric bypass surgery. Finally, weight loss procedures that rely on mucosa-to-mucosa approximation are by definition not durable. Similarly, procedures that force gastric tissue to be plicated, or approximated under tension without proper dissection and release from surrounding connective tissue are not likely to last.

I have developed gastric fundus invagination, GFI, after taking into consideration all these concerns. I believe that GFI is the future of bariatric surgery. Unfortunately, funding for a human trial is still not available to prove its efficacy, durability and most importantly GFI effect on gastric Ghrelin and Leptin secretion. In a future blog, I will explore the relationship between Ghrelin and Leptin secretion by gastric fundus tissue and the effect of these hormones on weight loss.

#### The Next Big Thing: What Is Driving Research In Bariatric, Metabolic and Foregut Surgery?
“Science and knowledge transform society. It is our moral obligation to contribute, support and defend the advancement of science against disease to improve human condition”.

The obesity epidemic has driven many scientists, epidemiologists and researchers to investigate the root cause of obesity. Our knowledge about weight gain, exercise, healthy lifestyle, hunger, satiety, metabolism and many other factors that contribute to obesity has exploded over the past few years. New paradigm shifts in clinical practice have opened the way for many obese patients to receive more effective, reliable and durable treatments. Diabetes is no longer considered a chronic progressive disease in the face of metabolic procedures like gastric bypass and gastric sleeve surgery. The concept “eat less and move more” has been replaced with “eat well and choose wisely” the calories you ingest. Exercise daily but don’t starve yourself. Neuro-hormones rather than will power control satiety, appetite, energy metabolism and body weight. The framework for future development of effective therapies for obesity has been set. New effective therapies, however, are not on the horizon.
Indeed, there has been not a single breakthrough in the treatment of GERD over the past 70 years ever since Dr. Nissen introduced his Nissen Fundoplication. Our understanding of GERD pathophysiology is still limited. Proton pump inhibitors have been mistakenly accepted as the gold standard of acid reflux treatment. Pharmaceuticals companies were happy with a steady supply of GERD patients getting dependent on daily proton pump inhibitors while acid reflux disease continued to progress. Endoscopic devices, like Stretta and TIF, for lower esophageal sphincter augmentation have limited efficacy. Recently, EndoStim, an electrical stimulation device of the lower esophageal sphincter, has been introduced. Clinical trials are currently being conducted.
Similarly, except for gastric sleeve surgery, we haven’t witnessed any breakthrough in the treatment of morbid obesity ever since Dr. Mason has introduced the gastric bypass more than 50 years ago. Many weight loss surgeons still talk about restriction and malabsorption as mechanisms for weight loss surgery. SOARD, the official journal of the American Society for Metabolic and bariatric Surgery still publishes articles debating the efficacy of gastric banding; we exalt the merits of gastric balloons and usher with great excitement the era of endoscopic sleeve gastroplasty. We have introduced procedures like gastric plication with great enthusiasm and hope. We watched in awe banded gastric plications being taught to community bariatric surgeons as the next best thing since sliced bread. Last but not least, a gastric pump has been recently approved to purge the stomach empty and some how cure the obesity epidemic. When is this trend going to stop?
“Medical research in a way is in crisis,” reports Dr. Ole Frobert, a cardiologist at Orebro University in Sweden. “We do a lot of research and publish a lot of papers, but there are very few breakthrough,” Frobert explains. Original research in the field of bariatric, metabolic reflux surgery must be guided by knowledge we gained from prior studies and observations. Shrinking the gastric volume and narrowing the lower esophageal sphincter should no longer be accepted as a guiding principle for device development for obesity or GERD treatment. Indeed, research purely driven by device creation to make a profit does not seem to improve our medical care nor does it transform our society. I am still hopeful that the current state of medical research in my field of expertise will change in the near future. We need to solve problems, resolve conflicts and improve care with innovative approaches that are yet to come.

#### The Nissen Sleeve Operation: A New Take on the Gastric Sleeve
A group of French bariatric surgeons from the University Hospital of Montpellier have conducted a pilot study on a new weight loss procedure called Nissen-Sleeve or N-Sleeve. The study was recently published in Surgery for Obesity and Related Diseases journal. The purpose of this hybrid procedure is to prevent acid reflux following gastric sleeve resection in GERD patients. 25 consecutive patients underwent the weight loss procedure from 2013 till 2014. 88% of the patients had a hiatal hernia and underwent a concomitant hiatal hernia repair. 8 patients had Barrett’s esophagus and 10 had esophagitis.

A 3-cm floppy Nissen fundoplication was constructed followed by gastric sleeve resection over bougie. The antrum was preserved and the gastric sleeve resection was extended up to the level of the fundoplication making sure to resect as much as possible of the gastric fundus.

At 6 months and one year 12% of the patients were still experiencing reflux which was proven by endoscopy and pH study. The remaining 22 patients were free of reflux related symptoms. Excess weight loss at one year was comparable to that of a standard gastric sleeve.

At Houston Weight Loss Surgery Center, we believe that a properly performed gastric sleeve surgery results in GERD resolution and is associated with very low leak rate. Therefore, we find no advantage of the Nissen-Sleeve modification. In addition, I think that fundoplication unlike resection, preserves part of the posterior gastric fundus. This in turn may lead to decreased weight loss. Both approaches, however, eliminate the post-prandial gastric accommodation reflex leading to decreased gastric volume, decreased gastric wall compliance and increased gastric emptying. Fundus resection reduces ghrelin secretion but fundus plication preserves gastric leptin function. From a weight loss point of view, the current study has shown equivalence between the traditional gastric sleeve and N-Sleeve. Future studies are needed to corroborate this fact.

The Nissen-Sleeve may play a role in revision gastric sleeve surgery for patient who develop acid reflux after sleeve gastrectomy. At this year, obesity week meeting in New Orleans, an anterior fundoplication post gastric sleeve surgery was shown as a viable option to control post-operative GERD related symptoms. A large retained gastric fundus contributes to acid reflux following gastric sleeve surgery especially in the setting of a hiatal hernia. Gastric fundus resection is a common gastric sleeve revision we perform at Houston Weight Loss Surgery Center and we have had very good results in term of GERD symptom control. Is anterior or posterior fundoplication superior to gastric fundus resection in revision cases? Is the leak rate lower? We hope additional studies coming up in the new year to answer these questions.

#### The Perfect Sleeve Gastrectomy to Prevent GERD
Lakisha from Houston sent this question: “I had gastric sleeve surgery 3 years ago and since then, my GERD has worsened. I am now taking a medication that my insurance is fighting me about paying for but I’ve tried everything else and this is the only med that works. I have also read extensively about this medication and the long-term effects of it. I truly would love another option rather than a medication with so many life-threatening side effects. Thank you.”
Dear Lakisha,
A properly performed sleeve gastrectomy does not only prevent acid reflux from developing but it also cures existing acid reflux. Here are the surgical steps for the perfect sleeve gastrectomy.

Repair any size hiatal hernia. There is a strong association between obesity and hiatal hernia. A hiatal hernia is more likely to develop with increased abdominal girth possibly due to increased intra-abdominal pressure forcing the stomach and to move upward into the chest area. More than 90% of Houston Weight Loss Surgery Center patients are found to have hiatal hernia on upper endoscopy prior to surgery. the purpose of hiatal hernia repair is to:

Bring the stomach and intra-abdominal esophagus back into the abdomen. This moves the gastro-esophageal junction or the reflux valve away from negative chest pressure to positive intra-abdominal pressure.
Mobilize and reduce herniated upper stomach from chest into abdomen to allow proper gastric sleeve resection.

Preserve the antrum which is the lower one third of the stomach. The antrum is the pump that contributes to food breakdown and emptying into intestine. Preserving the antrum accelerates gastric emptying and prevents food and acid stasis in sleeve lumen.
Avoid narrowing the incisura angularis, stomach angulation, at the junction of the upper two thirds and the lower one third of the stomach. Narrowing this part of the stomach is a recipe for acid reflux. For this purpose, stomach resection starts around 6 cm from the pylorus without a bougie in place. Only after navigating the incisura angularis, a bougie is placed along the lesser curvature and gastric sleeve resection is completed. Avoiding a functional obstruction at the level of the incisura angularis, is the most important step in gastric sleeve surgery.
Completely resect gastric fundus to avoid an acid pocket forming below the lower esophageal sphincter leading to acid reflux. The gastric fundus must be properly mobilized during surgery to allow for complete resection. Following complete mobilization, the gastric fundus is retracted laterally towards the spleen and then resected.

In your case Lakisha, I suspect the incisura angularis was narrowed during initial surgery. Consequently, acid reflux develops. Severe acid reflux causes a hiatal hernia to develop. This in turn further weakens the anti-reflux barrier leading to worsening acid reflux. Luckily the incisura angularis dilates over time and the functional obstruction resolves. Acid reflux, however, continues because a hiatal hernia has already developed. Medical treatment for GERD relies on proton pump inhibitors, (PPIs), like Dexilant, Nexium and Omeprazole. These medications are associated with long-term side effects. Furthermore, in the setting of sleeve gastrectomy, PPIs are not enough to control GERD related symptoms. At Houston Weight Loss Surgery Center, we offer hiatal hernia repair to restore the anti-reflux barrier. This approach is effective in controlling acid reflux in more than 95% of cases. If, however, the incisura angularis is still narrowed then the only solution to stop acid reflux is to convert your gastric sleeve to gastric bypass.

#### The rise of Gastric Sleeve procedure for weight loss
The rising Gastric Sleeve is replacing older and ineffective procedures like adjustable gastric banding. Gastric sleeve surgery is a metabolic procedure that alters several hormones that control appetite, satiety and energy metabolism. The end result is significant and durable weight loss. At Houston Weight Loss Surgery Center, we offer the gastric sleeve surgery as a first line weight loss surgery option for almost 80% of our patients. Gastric bypass surgery is reserved for revisions and advanced diabetes cases. We don’t offer adjustable gastric banding, however, we offer gastric band adjustments and management to patients who has already received a band. Our revision surgery mainly consist of band conversion to gastric bypass. Many band patients suffers from over restriction and esophageal dilation. We have noticed a a very high incidence of acid reflux in band patients secondary to esophageal dysmotility. For theses reasons, our go to option for band revision is gastric bypass surgery as it alleviates acid reflux in the setting of esophageal dilation and dysmotility much more effectively than gastric sleeve surgery.
Gastric balloon placement is a new option currently available on the market. Gastric balloon is not considered a metabolic procedure. It is rather a tool to rely upon for around 6 months to prevent you from overeating allowing you to loose between 30 to 50 pounds. Gastric balloon is placed endoscopically under intravenous sedation then removed 6 months later. During the 6 month period of balloon placement you will be coached by a nutritionist on a healthy lifestyle including eating right and exercising daily. Gastric balloon is not for everyone but could be a viable option for certain individuals.

#### Twisted Gastric Sleeve
A twisted gastric sleeve occurs when the gastric sleeve tube twists around its longitudinal axis by 180 degrees.

The twist involves the stomach area between the gastric antrum (lower one third of the stomach). The staple line of this part of the stomach turns counterclockwise from a lateral to medial position.

The twisted gastric sleeve lumen results in a functional obstruction leading to severe acid reflux after surgery.

Severe acid reflux causes a hiatal hernia to develop. A hiatal hernia further exacerbates acid reflux and within a year or two after initial gastric sleeve surgery, acid reflux symptoms become difficult to control with medications like Nexium and Protonix.
What Causes a Twisted Gastric Sleeve?
The cause of a twisted gastric sleeve is aggressive stomach resection resulting in the collapse of muscular scaffolding of the stomach. This kind of stomach mutilation, as I like to call it, results from three technical errors that must happen simultaneously:

 	More than 50% of the antrum is resected.
 	The incisura angularis (natural angulation of the stomach) is narrowed.
 	A very small calibration tube is used with uneven pulling on the posterior and anterior walls of the stomach during stomach resection.

How Is It Treated?
First-Line Approach
The treatment of twisted sleeve gastrectomy aims at restoring stomach anatomy, if possible, by sequential endoscopic dilation using special dilators balloons.

A total of 4 dilations can be offered. Each dilation aims at stretching the gastric sleeve lumen to allow the lateral staple line to move clockwise back to the lateral position.

The success rate of such an approach varies depending on the degree of “mutilation” and the duration of time since initial gastric sleeve surgery. Concomitantly, a temporary stent can be placed within the lumen of the stomach to promote stretching.
Surgical Option
If this first line endoscopic approach fails to untwist the gastric sleeve, conversion to gastric bypass is the only solution left, to alleviate acid reflux.
Can It Be Prevented?
Twisted gastric sleeve is a rare complication of sleeve gastrectomy. This complication is prevented only if your bariatric surgeon understands stomach anatomy and physiology as well as sleeve gastrectomy mechanism of action.

A competent bariatric surgeon preserves the gastric antrum, avoids narrowing the incisura angularis and maintains even traction on the anterior and posterior stomach walls during stomach resection.

A properly performed gastric sleeve surgery is both safe, and reliable. Most importantly, a properly performed sleeve gastrectomy does not cause acid reflux.
Suffering from Acid Reflux After Sleeve Surgery?
If you had a sleeve gastrectomy, and you currently suffer from acid reflux disease, give us a call at 832-945-8717. We can help you.

#### Understanding Gut Electrical Activity
The gastrointestinal tract is considered our second brain. Over one million neurons span the entire length of the GI tract and independently control complex activities like motility and digestion. Our understanding of this complicated neuro-endocrine system is still at its infancy. Yet, the implication of gut dysmotility and neuro-endocrine disturbances affect many aspects of our health including obesity, diabetes, acid reflux, gastroparesis, achalasia, and irritable bowel syndrome.

G-Tech Medical is a startup medical company founded in 2008 by Uday S. Devanaboyina. The founder’ goal is to understand gut electrical signals and motility patterns associated with certain diseases like irritable bowel syndrome, IBS. G-Tech has developed a waterproof wireless patch that attaches to the skin and measure electrical activity from the stomach, small intestine and colon. Steve Axelrod, PhD is concentrating on studying IBS and postoperative ileus. The patch, however, if validated as a reliable tool to measure gut electrical activity, can be extremely valuable in understanding the relationship between gut neural activity and obesity, diabetes, GERD and other disorders. Potential application of the G-Tech patch include:

 	Compare fasting to post-prandial gut electrical signals in patients with insulin resistance, obesity and type 2 diabetes.
 	Evaluate gut electrical activity before and after gastric sleeve and gastric bypass surgery to understand bariatric surgery mechanism of action.
 	The same way, we use an EKG to check for a myocardial infarction in a stress test, we can stress the gut with certain foods of varying glycemic loads and study changes in gastrointestinal electrical activity. We can also correlate these changes to variation in neuro-endocrine hormone secretion of GLP-1, PYY and Ghrelin.
 	Postprandial electrical signals can be studied in GERD patients and correlate between these signals and transient lower esophageal sphincter relaxation associated with acid reflux episodes.

G-Tech Medical is attempting to take the enteric nervous system out of obscurity. It is an endeavor that I wholeheartedly encourage and support. We hope their research and studies will find clinical applications that will help millions of patients in the near future.

#### Understanding The Biology of Obesity: Adipocyte Browning
More than 500 million people worldwide suffer from obesity. Obesity is a complex medical disease that is poorly understood. Scientists have not yet established a biological cause for obesity. Obesity has a strong genetic component involving several genes that regulate body weight, appetite and energy metabolism. However, the identification and characterization of a cause effect relationship between certain gene expression and obesity in humans has remained elusive until few days ago.
A new study published in the New England Journal of Medicine, demonstrates a causal relationship between a gene variant and fat accumulation in adipocytes. This fascinating article by Claussnitzer and colleagues is titled FTO Obesity Variant Circuitry and Adipocyte Browning in Humans. FTO gene has been associated with obesity but so far FTO mechanism of action has not been understood. The authors propose that certain variants of the FTO gene change the basic function of human adipocytes from fat storage to fat burning. When exposed to a high-fat diet, adipocytes in white adipose tissue store fuel as triglycerides for later use. In contrast, brown adipocytes in the inter-scapular regions of infants, young adults, and some older persons generate heat by burning fat. A third type of adipose tissue, often called “beige,” or “brown-like” fat, is found in some white adipose tissue depots. Beige adipocytes like the brown ones have thermogenic properties. They can burn fat. It has been hypothesized that obese persons have fewer beige adipocytes and therefore are primed to gain weight on high-fat diets.
By showing that FTO gene controls adipocyte development into either a white (fat accumulating cell) or beige (fat burning cell), this original study explains the strong genetic association between obesity and FTO gene. The study offers a potential biologic pathway that leads to fat accumulation in adipocytes. Future research will focus on how FTO, which is highly expressed in several tissues, can affect other organs. The creation of a knock-in mouse with high-risk FTO alleles should facilitate the determination of the contribution of these gene variants to obesity. It would be interesting to study gastric bypass or gastric sleeve surgery in a knock-in mouse model with high-risk FTO alleles. Will the surgery be less effective? Or will the neuro-hormonal changes induced by weight loss surgery trump the FTO induced reduction in energy metabolism?
Our knowledge of obesity and weight loss surgery mechanism of action remains at its infancy. Obesity is a complex disease with many overlapping pathways that control appetite, weight and energy metabolism. It is quite amazing that a simple procedure like gastric sleeve can overcome all these pathways to achieve significant and durable weight loss. One cannot but wonder about the central role of the stomach and more specifically the gastric fundus in energy metabolism. The simple resection of gastric tissue, following gastric sleeve surgery, changes the interaction between ingested food and gastrointestinal tract. This change results in decreased appetite, weight loss and improved blood sugar control. Bile acid metabolism, colonic intestinal flora, gastro-intestinal motility as well as a number of hormones like GLP-1, PYY and Ghrelin levels are altered. How and why do these changes occur when the stomach is resected is still a mystery. Despite the obesity epidemic affecting millions of people, the only effective treatment available in the twenty first century is a surgery that we don’t understand how it works. This is no surprise as we are just starting to understand the role of the gastrointestinal tract as an endocrine organ. Bariatric surgery has been assumed to work by restriction and malabsorption for the past 50 years. Nutrient sensing and the resultant complex array of signals that reaches the brain, pancreas, liver and the rest of the intestines are very new concepts. Total deaths from diabetes alone are projected to rise by more than 50% in the next 10 years. Hopefully our understanding of gut physiology and its role in blood sugar regulation and energy metabolism will keep up with the rise of gut related disorders like diabetes and obesity. In future blogs I would like to share with you some of my views about the role of the stomach in nutrient sensing and processing and how Gastric fundus invagination, a novel weight loss procedure, is at the center of all this.

#### Walking In Houston: We May Have A Problem
A recent article published in JAMA has caught my attention. It is about regular daily walking and getting our patients and the general population to move. Walking is easy but it is hard for doctors to convince and motivate their patients to do it. Studies blame our current environment. Sallis JF et al showed in a recent epidemiological study in 14 cities across the world that people who lived in the most active-friendly neighborhoods, walked 68 to 89 more minutes every week. Houston may be the least active-friendly city in the states. Unlike Austin and San Antonio, cycling in Houston is almost non-existent. Access to public transportation, and parks is not easy. Houston is rather big on restaurants, valet parking and “Texas Limousines”. Houston is also notorious for being one of the most stressful cities in America. The combination of stress, diminished physical activity and rich food in fat, salt and animal products is a sure recipe for obesity, diabetes and cardiovascular disease.

In 2007, Oklahoma City Mayor Mick Cornett announced a goal for the 600 000 people of his city to collectively lose 1 million pounds. He added a 70-acre downtown park and hundreds of miles of sidewalks and trails. Within 5 years, the city met Cornett’s goal, losing a million pounds. Daily walking is probably one of most beneficial forms of exercise to maintain a healthy lifestyle. Indeed, a recent meta-analysis of studies about exercise and mortality showed that a sedentary person’s risk of dying prematurely from any cause decreased by 20 percent if he or she began brisk walking. Booth el al. showed that better designed neighborhoods for walking are associated with lower prevalence of obesity and diabetes.

So what can you do? Obviously, changing the landscape in Houston is not an overnight endeavor. You can, however, start walking. Take the stairs instead of the elevator at work. Walk to your local grocery store or coffee shop. Get a bicycle and start hitting some of the cycling trails in town. Check www.houstonbikeways.org for new projects being developed in Houston to allow for safe biking round the city. Make an effort to develop a habit of walking at least 10,000 steps per day. Maybe a pedometer or one of the many wearable health devices on the market may help motivate you. Consider getting a treadmill desk for you office if you spend most of your day sitting.

The bottom line is that we need to move because it certainly improves your health, prevents weight gain, and prolong longevity.

#### Weight Loss after Gastric Sleeve to Bypass Conversion
Sally sent us this question: “I had gastric sleeve surgery and have successfully lost my excess weight. I struggle however with severe acid reflux and I need to convert to gastric bypass. What will happen with weight loss?  I don’t have any extra weight to lose. Thank you”
Dear Sally,
Acid reflux after sleeve gastrectomy develops secondary to unrepaired hiatal hernia and/or narrowed gastric sleeve lumen. Fortunately, narrowed gastric sleeves are rarely encountered these days as most bariatric surgeons in Houston have mastered the proper technique of sleeve gastrectomy. A properly performed sleeve gastrectomy is associated with high success rate in terms of weight loss. However, if a concomitant hiatal hernia is not repaired at the time of sleeve gastrectomy, weight loss surgery patients will struggle with severe acid reflux symptoms. Hiatal hernia repair in this situation is more than 95% successful in stopping acid reflux. There is no need to convert a well performed gastric sleeve to gastric bypass to control acid reflux.
In cases of narrowed gastric sleeve lumen, hiatal hernia repair by itself is not enough to control GERD related symptoms. Conversion of gastric sleeve to gastric bypass is required to stop acid reflux. Weight loss, however, following sleeve to bypass conversion is limited. Numerous studies in the literature have shown modest weight loss after sleeve to bypass conversion. Indeed, both sleeve gastrectomy and gastric bypass alter gastrointestinal hormone secretion by increasing gastric emptying into small intestine and stimulating intestinal neuro-hormonal signals that favor weight loss. Both surgeries have overlapping mechanisms for weight loss and there is very little additional weight loss with sleeve to bypass conversion.
In conclusion, acid reflux after sleeve gastrectomy is first managed by repairing the hiatal hernia. Second, if acid reflux persists or if the sleeve lumen is narrowed, sleeve to bypass conversion can be safely performed. Additional weight loss after sleeve to bypass conversion is limited.

#### Weight Loss and Health Wearables
Wearable health devices and health related apps are flooding the market. From heart monitors to sleep trackers, patients have a wide array of models to choose from. Today, I had a nice chat with one of my gastric sleeve patients, Sharon, in the office. She is 5 months out of surgery and she is feeling FANTASTIC after losing 75 lbs. She is off her high blood pressure medications, her low back pain has resolved and she is finally able to walk, dance and workout every day. Sharon reports lot of energy. She is no longer tired and fatigued throughout the day. Sharon is using Fitbit CHARGE to track her calorie intake, daily water consumption and number of steps per day. She is logging more than 25,000 steps on average every day. She loves her Fitbit. It gives her important feedback on how many calories she is consuming but more importantly how many steps she is walking or jogging. She has made several “Fitbit” friends across the world with whom she engages in several fitness challenges that motivate her and help her stay on track.
Do we really need a Fitbit to improve our fitness? Our hectic and sedentary modern lifestyle may require such health and fitness trackers. After learning about Fitbit today I realized that I spent the whole day in office seeing one patient after another without drinking a drop of water. I was sipping on coffee all day and when I was done working I took the elevator instead of the stairs. On the way out, walking to my car I came across our receptionist who was doing laps around our office building trying to increase the number of steps on her own Fitbit!! I felt really bad and I drove straight ahead to the nearest shop and bought a Fitbit for myself. I also bought the Fitbit scale to monitor my weight too. At the end of the day, we have to be proactive, like Sharon and the receptionist, about our health. Do whatever it takes to increase our level of activity in the midst of our sedentary lifestyle. Sharon keeps her step numbers up by walking around the island of her kitchen when working at home and around her office building when working at her company headquarter in downtown Houston. Sharon has made the commitment after her gastric sleeve surgery to lose weight and improve her health. No wonder she has lost 75 pounds in 5 months. For the year of 2016, let us all be a Sharon. Let us track and record our food intake, heart rate, and steps we take. Let us invest in our health for more than 80% of our modern life health issues are directly linked to lifestyle. What you eat and how much you exercise affects your longevity, your well-being and ultimately your happiness.

#### Weight Loss Around Thanksgiving
2022 holiday season is about to start. Thanksgiving this week kick starts a period of celebration, family reunions, and overeating. Indulging in rich food and binging on pumpkin and pecan pies is the rule. Most Houstonians, finish the holiday season 3 to 4 pounds heavier. How can you avoid holiday weight gain?

There is no magical solution. Short of abstaining from overeating, you are very likely to gain weight. We advise mindful eating, but it is easier said than done. Food is a big part of the holiday season, and we all want to celebrate with friends and family.

The more you eat, the more you want to eat especially when you are consuming high carbohydrate and sugar content food like pumpkin pies and mashed potatoes. During holidays, we feel ravenous. We eat when we are not hungry, and we consume food beyond our satiation levels.

Fasting for a few days before the holidays suppresses your appetite and regulates your hormones. Fasting helps you to be more mindful when feasting during holidays. You may be less tempted to overindulge. You may also avoid eating when not hungry. Intermittent fasting with a concomitant ketogenic diet that is low in carbohydrates and high in healthy fats is equally effective in preparing your body to the holiday feast.

During holiday mealtime, we recommend you start with a salad first as well as non-starchy vegetables like brussels sprouts and asparagus. Make sure you are well hydrated before you start eating. Then eat your proteins and finally try the mashed potatoes, bread, fruits, and desserts if you must. Filling your stomach with water, fiber, then fat and protein and leaving carbohydrates till the end prevents blood sugar and insulin spikes. Insulin spikes increase your appetite and decrease protein, fat, and carbohydrate breakdown in your body. This leads to increased eating, and weight gain.

#### Weight Regain after Bariatric Surgery
A recent study by Courcoulas et al titled “Patient behavior and Characteristics Related to Weight Regain after Roux-en-Y gastric Bypass” highlights certain behaviors associated with weight regain years after bariatric surgery. This is a large prospective study of 1278 adults who underwent bariatric surgery between 2006 and 2009 with annual and semi-annual follow-ups s for up to 7 years. Median weight loss was 37% of pre-surgery weight while median weight regain was 25% from nadir. The authors found that a sedentary lifestyle and fast food consumption were independent risk factors for weight regain. Similarly, continuous eating, eating when full and binge eating contributed to weight regain.

At Houston weight Loss Surgery Center, I stress the importance of changing behavior, food culture, and eating habits to maintain weight loss after bariatric surgery. Weight loss surgery alters gastrointestinal hormones like GLP-1 and PYY that improve blood sugar control, increase satiety and promote weight loss. Poor eating habits, like fast food consumption, after weight loss surgery, ruin these beneficial hormonal changes leading to weight regain. Long-term weight loss maintenance following weight loss surgery depends on a healthy lifestyle. As the study by Courcoulas el al shows, avoiding processed food and a sedentary lifestyle constitute one of the components of healthy living.

#### What Does Healthy Eating Mean?
All of these rules are subtly trying to get you to be more conscious of what you’re eating. It’s far too easy these days to consume more than you think you are, or more than you really need, especially when eating out. I’ve found that it’s impossible to tell any one person how much they should be eating. People have varying requirements, and it’s important for all of them to listen to their bodies to know when they should eat, and when they should stop.

Get as much of your nutrition as possible from a variety of completely unprocessed foods. These include fruits and vegetables. But they also include meat, fish, poultry and eggs that haven’t been processed. In other words, when buying food at the market, focus on things that have not been been cooked, prepared or altered in any way. Brown rice over white rice. Whole grains over refined grains. You’re far better off eating two apples than drinking the same 27 grams of sugar in an eight-ounce glass of apple juice.
Eat lightly processed foods less often. You’re not going to make everything yourself. Pasta, for instance, is going to be bought already prepared. You’re not going to grind your own flour or extract your own oil. These are meant to be eaten along with unprocessed foods, but try to eat less of them.
Eat heavily processed foods even less often. There’s little high-quality evidence that even the most processed foods are dangerous. But keep your consumption of them to a minimum, because they can make it too easy to stuff in calories. Such foods include bread, chips, cookies and cereals. In epidemiologic studies, heavily processed meats are often associated with worse health outcomes, but that evidence should be taken with a grain of salt (not literally), as I’ve written about before.
Eat as much home-cooked food as possible, which should be prepared according to Rule 1. Eating at home allows you to avoid processed ingredients more easily. It allows you full control over what you eat, and allows you to choose the flavors you prefer. You’re much less likely to stuff yourself silly if you eat home-cooked food. I’m not saying this is easy. Behavioral change takes repetition and practice. It also, unfortunately, takes time.
Use salt and fats, including butter and oil, as needed in food preparation. Things like salt and fat aren’t the enemy. They are often necessary in the preparation of tasty, satisfying food. The key here is moderation. Use what you need. Seasoning is often what makes vegetables taste good. Don’t be afraid of them, but don’t go crazy with them either.
When you do eat out, try to eat at restaurants that follow the same rules. Ideally, you should eat at restaurants that are creating all of their items from completely unprocessed foods. Lots and lots of restaurants do. Follow Rule 1 even while out to dinner. Some processing is going to be fine, but try to keep it to a minimum.
Drink mostly water, but some alcohol, coffee and other beverages are fine.  As I’ve pointed out before, you can find a study to show that everything either prevents or causes cancer — alcohol and coffee included. But my take is that the preponderance of evidence supports the inclusion of a moderate consumption of most beverages.
Treat all beverages with calories in them as you would alcohol. This includes every drink with calories, including milk. They’re fine in moderation, but keep them to a minimum. You can have them because you like them, but you shouldn’t consume them as if you need them.
Eat with other people, especially people you care about, as often as possible. This has benefits even outside those of nutrition. It will make you more likely to cook. It will most likely make you eat more slowly. It will also make you happy

I’ve avoided treating any food like the devil. Many nutrition experts do, and it may turn out they’re right, but at this point I think the jury is still out. I’ve therefore tried not to tell you to avoid anything completely. My experience tells me that total abstinence rarely works, although anecdotes exist to support that practice. I think you’ll find that many other diets and recommendations work under these rules. These are much more flexible and, I hope, reasonable than what some might prescribe.
These recommendations were written by Michael Pollan, an American author, journalist, activist, and professor of journalism at the UC Berkeley Graduate School of Journalism.

#### What Exactly Is the Magenstrasse?
Gastric emptying is a complex and highly coordinated process that remains poorly understood. Several nutrient stimulated neuro-hormonal signals emanating from the gastro-duodenal control gastric emptying. Since we lack the tools to measure in-vivo gastric emptying James Brasseur, a bio-engineer, at the university of Pennsylvania, developed a computer simulation model of the stomach. Using this model, Brasseur et al were able to numerically calculate intra-gastric fluid motions. In 2006, they published an interesting study, in the journal of Biomechanics, titled “A Stomach Road or Magenstrasse for Gastric Emptying”. In this study, Brasseur demonstrates the existence of early post-prandial rapid emptying. The emptying pattern occurs along the lesser curvature and channels food particles from the fundus into the duodenum before any significant digestion has occurred. The researchers found that gastric fundus contractions in coordination with gastric antrum contractions results in Magenstrasse emptying pattern.

Why does the Magenstrasse exist? The authors of this interesting article explain that a “spot of highly concentrated lipid or glucose in liquid or semi-solid form… rather than waiting patiently in the fundus while the antrum and corpus empties… moves rapidly along the Magenstrasse, bypassing most of the fundus, corpus and antrum, and enters the bowels rapidly in highly concentrated form and leaving behind 77% of gastric content”. This sounds like a Roux-en-Y gastric bypass procedure or sleeve gastrectomy mechanism of action. For Brasseur el al, however, the only potential usage of the Magenstrasse is rapid drug delivery into the intestines. In fact, in 2006, the mechanism of action of bariatric surgery was still unknown. Accelerated gastric emptying and dumping to stimulate neuro-endocrine hormones like GLP-1 were not described at that time.

In my opinion, dysfunction in the Magenstrasse gastric emptying results in diseases like obesity, type 2 diabetes, gastroparesis and GERD. Weight loss surgery in the form of gastric bypass and sleeve gastrectomy restores the dumping function of the Magenstrasse. The Magenstrasse emptying pattern is crucial to maintaining healthy gut to food interaction. Brasseur el al have found that “The strength of antral motility relative to fundus-induced contractions affects the extent and density of the Magenstrasse”. The coordination of contractile waves between gastric fundus, where food is received, and gastric antrum, where food is ground and mixed, determines the magnitude of the Magenstrasse. Surgical manipulation of the gastric fundus in the form of sleeve gastrectomy seems to restore the Magenstrasse emptying leading to resolution of obesity and diabetes.

Gastric fundus invagination or sleeve gastrotomy brings the gastric fundus in close proximity to the antrum. It would be interesting to apply Brasseur’s mathematical gastric model to study the effect of sleeve gastrotomy on fundic and antral contractions and their effect on the Magenstrasse. I predict that gastric fundus invagination restores the Magenstrasse leading to weight loss, diabetes resolution and possibly curing gastroparesis similar to sleeve gastrectomy.

#### What In The World?
The FDA has just approved, yet another stellar device for weight loss, called AspireAssist.  AspireAssist is, you guessed it, an endoscopic and reversible procedure. I don’t think they are calling it weight loss surgery without the surgery, yet. I am sure, however, that the description will surface at some point. The procedure is being advertised as very safe. Indeed, it is much safer than those “invasive and irreversible surgeries like gastric sleeve and bypass”. According to the company website, the one year complication rate of gastric sleeve surgery is 24% compared to 3.6% for AspireAssist. It is also very effective with 37% loss of excess weight during the first year after implantation according to information I read on the company website www.aspirebariatrics.com. The device will bridge the huge treatment gap that currently exists between medical and surgical management of obesity.

As usual, AspireAssist is described as the next best thing since sliced bread. A drainage tube is endoscopically placed into the stomach and through the skin under light sedation. Following each meal, patients connect an aspiration pump to the device to aspirate ingested food preventing calorie absorption. Patients are instructed to chew their food very well in order not to clog the tube/pump. Interestingly, the device is described as a tool that will help patients develop healthy eating habits, make good food choices and eat smaller portions!! How can patients develop healthy eating habits by overeating then pumping their stomach empty through AspireAssist is left to your imagination? The device developers further claim that after a year or two, patients can potentially remove the device and maintain the weight loss. Really?

Once again, we painfully witness the introduction of a new weight loss procedure to the US market that makes absolutely no sense. And once again the FDA approves it. Yes we are facing an obesity epidemic and yes surgery is invasive and expensive. (It is very safe, however, and not associated with a 24% complication rate). These facts, however, don’t justify the use of techniques and approaches that contradict knowledge about obesity and weight loss, we have acquired over the past 40 years. Calorie restriction by itself is not a reliable solution for permanent weight loss in obese patients. Let me repeat this statement: ” Calorie restriction by itself is not a reliable solution for permanent weight loss in obese patients”. This concept has been CLEARLY established. We are morally and ethically obligated to support and defend the advancement of science in the fight against disease to improve human condition. Is AspireAssist a scientific discovery and does it improve human condition? I don’t think so. Any weight loss procedure that does not address the underlying obesity pathophysiology is by definition not a weight loss procedure. Call it anything else except weight loss procedure and please do not compare it to gastric bypass and gastric sleeve surgery. This is wrong.

The field of metabolic surgery is currently going through the dark ages of innovation and development. Greedy investors and capitalists are taking advantage of the current obesity epidemic to make fast and short-term gains. We call on the American College of Surgeons and American Medical Association (I am excluding the American Society of Bariatric and Metabolic Surgery on purpose) to halt this phenomenon and focus our resources on genuine scientific endeavors that will help us fight the epidemic of the century.

#### What is Gastric Plication?
Gastric plication also known as greater curvature plication is a new procedure for weight loss that was introduced few years ago to the United States. The procedure involves reducing the gastric size by folding the stomach wall inside its lumen. Stitches are then placed to hold the folded stomach in place. The surgery mechanism of action for gastric plication is restriction, i.e. forcing the patient to eat less by reducing stomach size. This assumption has never led to any durable weight loss throughout the history of bariatric surgery.
Unlike sleeve gastrectomy or gastric bypass there is no stapling or cutting. The procedure was introduced to the public as safe, less invasive and as effective as a sleeve gastrectomy. Some surgeons went on to add an adjustable gastric band to gastric plication, assuming that the more restriction the better. Within 2 to 3 years, the initial enthusiasm about this novel procedure quickly faded. Weight loss, as expected, was not that great. Patients had excessive nausea and vomiting after surgery. The folded stomach herniated through the suture line causing leaks in certain cases. Hunger feeling was not controlled most likely because gastric plication did not decrease hunger hormones like Ghrelin. As a result weight loss was not sustainable and gastric plication failed to prove itself as a safe, durable and effective weight loss procedure.
Understanding weight loss surgery mechanism of action is crucial for the development of new effective weight loss procedures. Obesity is a complex multifactorial disease that results in functional deficiency of many neuro-hormonal signals that would normally arise after a meal. Restoring these signals, rather than restriction, should be the guiding principle for developing new weight loss procedures.

#### What is hunger?
Hunger and the desire to eat are two different entities. Hunger is hormonal, but the desire to eat is emotional. We need to eat to replenish our energy stores and maintain our metabolism. Hunger drives us to seek food to survive. Hunger subsides after eating enough food or a regular size meal. The desire to eat, on the other hand, is emotional. We eat when we are sad or happy. We crave ice cream to compensate for certain events in life. We snack on food throughout the day to cope with stress or boredom. We seek “comfort food” rich in saturated fat, sugar and salt. Slowly we develop habits of unhealthy eating that become entrenched in our daily life. Habits become second nature and very soon we become victims of a highly processed diet rich in sugar, salt and fat.
In today’s environment, we consume more than what we really need because the desire to eat has trumped the natural feeling of hunger. We no longer listen to our bodies to know when to eat, what to eat and how much to eat. At Houston weight loss surgery center, we spend lot of time educating our patients on “mindful” eating habits:

Have 3 meals a day. Do not skip breakfast. In fact let breakfast be the most important meal of the day. Avoid grazing on small amounts of food throughout the day.  Avoid eating while driving or watching TV. Give yourself time to enjoy a meal and listen to your body, as you are getting full. Do not overeat. Instead stop eating shortly before you feel you are full.
Avoid SUGAR. Sugar is the enemy of weight loss. Sugar increases your appetite and decreases your metabolism. Sugar will ruin any weight loss attempts and significantly contributes to weight regain after bariatric surgery.
Snacks: The purpose of a snack is to simply hold you over to your next meal.  Do not consume calorie rich snacks like potato chips and candy bars. Rather choose fruits and vegetables for snacking. You may use nuts from time to time but remember nuts are rich in fat and calories. Do not consume more than 100 calories per snack.
Craving certain food items can wreck havoc on your weight. We usually crave high fat high sugar food that adds hundreds of calories per day. Here are some healthy alternatives:

Craving Crunchy
Veggie sticks, such as celery, carrots, red bell peppers and fennel, are water rich and will help to suppress your appetite while satisfying your craving for crunchy.
Craving Comfort
Oatmeal can be a great high-fiber, snack any time of day— it’s not just for breakfast. Low fat, sugar free yogurt is another option.
Craving Protein
Working a little protein into your snacks is a great way to fuel your day and keep unhealthy cravings at bay. Keep a few hard-boiled eggs in the fridge at home or at work. When you pack your lunch, add a couple of pieces of sliced turkey rolled in lettuce for midday snacking. Low-fat cheese sticks and cottage cheese are also good.
Craving Sweet
Fresh berries, including blueberries, strawberries, blackberries and raspberries, all contain fiber and an abundance of natural sweetness.
Craving Fried Foods
Oven-baked fried chicken strips can be a surprisingly good alternative to greasy wings. Substitute baked sweet potato fries, a sweet and crunchy snack, for traditional french fries.
Craving Ice Cream
Create your own low-fat, creamy alternative to ice cream. Try frozen peaches blended with coconut milk and chilled in the freezer. Frozen strawberries blended with ice, low-fat yogurt and a banana makes a great smoothie.

#### What is Mindful Eating?
Allowing yourself to become aware of the positive and nurturing opportunities that are available through food preparation and consumption by respecting your own inner wisdom.
Choosing to eat food that is both pleasing to you and nourishing to your body by using all your senses to explore, savor, and taste.
Learning to be aware of physical hunger and satiety cues to guide your decision to begin eating and to stop eating.
Acknowledging responses to food (likes, neutral or dislikes) without judgment.

Thoughts That Flavor the Meal
By Megrette Fletcher, M.Ed., R.D., CDE
It is amazing to notice how much thoughts can influence whether a situation is viewed as “good” or “bad.” It is common for those scheduled for bariatric surgery (and even after surgery) to have worries about the unknown, hopes and expectations for the future, and questions related to the surgery itself. If these types of thoughts are present when eating, consider trying this suggestion. Before you take a bite, pause and fill your lungs with air. Then slowly let the breath out. Now, observe the food before you. Look at it, noticing any labels of “good” or “bad,” “allowed” or “forbidden.” If this is hard to do, take another breath and slowly exhale – relax. Allow yourself to be a witness to the experience of eating a meal: Its shape, color and texture. Now, take a bite. Let it rest in your mouth for a moment before chewing. With your next bite, notice how the food feels in your mouth. Is the bite size comfortable? Does it feel too big to chew easily or too small to really taste the flavor? If the size of the bite was not pleasant, adjust the amount you select so you can actually taste the bite, chewing it a little bit longer each time before you swallow. Experiment with sizes and how long you chew each bite.
Now that you have had a few bites, ask yourself: Did slowing down and chewing my food feel new, different, or maybe a bit uncomfortable? Eating in a mindful way allows you to “wake up” and notice new things. These things may include taste, texture, or even how much food is selected for each bite. Frequently the information received does not stop there. When a person eats mindfully, she may notice how some thoughts can trigger anxiety, anger and desperation, making these emotions part of the meal.
If uncomfortable feelings are present while eating, take a deep breath. Fill your lungs with air, and then slowly let this air out. Remind yourself that you are not “bad,” “stupid,” “a failure” or “wrong.” These are just the thoughts and feelings that are with you. They are not facts.
For many individuals, the thoughts that are present when eating contribute a large part to how the meal tastes. An important question to ask is: Are these thoughts helping me enjoy the food in my mouth? Practicing mindful eating is more than seeing what and how much you eat. It is learning to welcome the thoughts that are present when you eat. This process of opening up can profoundly change the taste of the bite. At times you may realize it is your thoughts that are actually flavoring the meal. Noticing each bite can help you season the meal with thoughts you enjoy.
Megrette Fletcher, M.Ed., R.D., CDE, is a cofounder of TCME. She is a diabetes educator and contributes to the blog site mindfuleatinganddiabetes.com. She can be reached at megrette@megrette.com.

#### What Type of Exercise Is Good for You?
Exercise intensity, duration and frequency varies greatly among individuals. It is commonly recommended to do 150 minutes of moderate intensity aerobic activity or 75 minutes of vigorous exercise every week. In this current issue of Current Cardiology Reports, Robert W. McGarrah el al demonstrate that moderate-intensity aerobic exercise improves insulin sensitivity more than vigorous-intensity aerobic exercise when total energy expenditure is controlled for.

The exact physiologic mechanisms underlying this difference are not well understood. However, the implications of such an observation on our daily life are significant. Maintaining a daily routine of low to moderate intensity aerobic activity is sufficient to fend off insulin resistance and all other associated diseases like type 2 diabetes, obesity, inflammation, and cardiovascular disease. Walking or cycling back and forth to work daily, as well as using the stairs are for example activities that may keep you healthy and allow you to live longer. A study published in JAMA Internal Medicine last year analyzed around 650,000 individuals regarding their exercise habits. The researchers found that those who walked around one hour every day were 39% less likely to prematurely die than those who never exercise. Individuals who exercised longer than one hour a day did not gain any additional benefits in terms or mortality risk reduction.

While the optimal dose of exercise will continue to be a subject of debate, there is no doubt that some form of daily activity is needed to maintain your body, boost your metabolism and prevent weight gain. Leading a sedentary lifestyle is associated with premature death. The good news is that you don’t have to participate in an ironman or a Spartan race every couple of months to maintain your fitness. McGarrah and colleagues show us in this article that walking daily is enough to keep you healthy.

Start walking this holiday season. Make a commitment for the new year to walk at least one hour a day. Maybe later you want to add some strength training or participate in a sport. The bottom line is that you must incorporate some form of activity in your life along with healthy food choices to live longer and happier. This is especially relevant to our bariatric patients who has undergone a gastric sleeve or bypass procedure this year. To maintain the weight loss that you have worked so hard to achieve, Houston Weight Loss Surgery Center recommends 60 minutes of daily exercise. Incorporate aerobic activity, yoga, stretching and weight lifting. Weight loss surgery patients who work out on a regular basis tend to be the most successful in maintaining their weight loss for years to come.

#### When Can I stop Mounjaro and Ozempic?
“I have lost 40 pounds on Mounjaro. Can I stop it now?”
Mounjaro and Ozempic are a once weekly injection medication for weight loss. Mounjaro and Ozempic mimic the metabolic effects of sleeve gastrectomy and gastric bypass by stimulating GLP-1 (Glucagon-Like peptide one) receptors in the brain, pancreas, and other parts of the body. This results in decreased appetite and hunger, increased satiety, decreased blood glucose level, and weight loss.
GLP-1 is normally secreted by specialized cells in the intestines in response to food intake. GLP-1 secretion in response to a meal is blunted in patients with obesity and diabetes. GLP-1 agonist supplementation in the form of Mounjaro and Ozempic does not cure this problem. Therefore, overweight patients on Mounjaro or Ozempic need to continue this medication for the rest of their life to maintain weight loss. Patients who stop Moujaro or Ozempic when they achieve desired weight loss experience increased hunger and appetite leading to increased food intake and weight regain.
Unlike Mounjaro and Ozempic, metabolic surgery like Sleeve gastrectomy alters your body’s natural GLP-1, PYY, Ghrelin and many other hormones in response to food intake. This hormonal change is central to sleeve gastrectomy weight loss mechanism of action. Reducing stomach size by itself does not result in sustainable weight loss. This is the case with endoscopic sleeve gastroplasty, ESG. This endoscopic procedure is metabolically inert. Weight loss is limited and so is the resolution of obesity related co-morbidities like type 2 diabetes.
In summary, you need to continue Mounjaro or Ozempic weekly injections for life to maintain weight loss. Long-term side effects of these medications are still unknown. If you are interested in stopping Mounjaro and restoring your body’s natural GLP-1 secretion, then you may want to consider metabolic surgery like sleeve gastrectomy.

#### Who Would Have Thought About It: Gastric Balloon and Pancreatitis?
The FDA has recently confirmed that fluid filled intra-gastric balloons used for weight loss can cause acute pancreatitis. It is believed the inflated intra-gastric balloon compresses pancreas tissue resulting in Pancreatitis. Pancreatitis patients typically present with severe back and abdominal pain as well as nausea, vomiting and fever. If not addressed early, pancreatitis may rapidly progress resulting in systemic inflammation that may lead to death. 

Patients who have undergone balloon placement need to be aware of pancreatitis symptoms. Should any of these symptoms develop, we recommend gastric balloon patients to contact their bariatric surgeon or present immediately to the nearest emergency room. A simple blood test can confirm the diagnosis of pancreatitis. If confirmed, gastric balloon must be immediately deflated and removed. 

We still don’t know the risk factors associated with pancreatitis development in the setting of intra-gastric balloon placement. Obalon, a gas filled intra-gastric balloon has been recently introduced into the Houston area. Obalon requires no endoscopy for insertion. The balloon is rather swallowed as a capsule then inflated in the stomach. The company representative claims that Obalon being lighter than Orbera and Reshape balloons is unlikely to be associated with pancreatitis. Furthermore, Obalon, being a lighter balloon, is thought to cause less nausea, vomiting and discomfort than heavier fluid filled intra-gastric balloons. 

At Houston Weight Loss Surgery Center, we remain hesitant to recommend gastric balloons for weight loss. Purely restrictive procedures are not associated with durable weight loss. Gastric balloons do not alter the metabolic signals that control energy metabolism weight and appetite. For patients, however, interested in loosing few pounds before a wedding or a trip to the beach gastric balloon may be a great yet expensive, temporary solution.

#### Why Diet Before Weight Loss Surgery?
All weight loss surgeries require changes to your diet. By making healthy choices before surgery, you can prepare your body for the procedure, improve your recovery and lose weight faster.
At Houston Weight Loss Surgery Center, we often ask patients to start a low-calorie, high protein liquid diet before surgery. Losing weight before surgery helps your body use its glycogen/fat stores, which shrinks the liver and makes surgery easier and safer.
The length of your low-calorie, high protein liquid diet will depend on your height, weight and type of procedure. The time frame is set based on your situation and how much weight you need to lose before surgery.
Benefits of dieting before surgery 
By losing weight before surgery, you’ll spend less time in the operating and recovery rooms. You will also be less likely to have health problems after surgery. Dieting before surgery also helps to:

Shrink liver and stomach fat
Prepare you for the diet guidelines after surgery
Reduce health risks after surgery

Drink at least three high-protein supplements per day.
Allowed foods:

Unlimited
2-3 servings per day:
Three servings per day: Protein supplements 
Choose four servings of the following per day:

Water
Crystal Light
Decaffeinated coffee or tea

 

½ cup Sugar-free Jell-O
½ cup Sugar-free popsicles

 

1 scoop of whey protein isolate mixed with 1 cup skim milk
1 scoop of whey protein isolate mixed with 1 cup diet juice
1 scoop of whey protein isolate mixed with ½ C Cream of Wheat

1 cup skim Milk
1 cup low-sodium tomato juice
½ cup sugar-free pudding
½ cup Low-fat or 2% cottage cheese
½ cup Non-fat plain Greek yogurt
½ cup Cream of Wheat

 

 

#### Zero Calorie Artificial Sweeteners Cause Diabetes and Obesity
Short-term exposure to artificial sweeteners in human volunteers induces elevated blood glucose levels and glucose intolerance. Aspartane, sucralose and saccharine are common food additives that millions of people use in hope of preventing diabetes or controlling blood sugar levels. These zero calorie substances are not absorbed by the body and hence should have no effect on body weight or metabolism. The reality, however, is completely different. Several studies have shown an association between diet soda consumption and the development of obesity and diabetes. For obesity and diabetes develop secondary to a change in metabolism. Our metabolism is controlled by neuro-hormonal signals that regulate body weight and glucose levels. Certain substances irrespective of calorie content may damage this delicate balance favoring elevated insulin levels and fat accumulation.

Understanding the underlying mechanisms of these observations can help us unravel effective therapies for the obesity and prevent the development of diabetes. Both diseases affect millions of people around the world. One such mechanism is related to gut microbiome. A study published in Nature in 2014 by Eran Elinav shows that artificial sweeteners increase glucose levels in mice. Since these substances are not digested or absorbed into blood the investigators hypothesized that artificial sweeteners affected gut microbes. The change in gut bacteria induced glucose intolerance. To prove their theory, they first fed mice saccharine and showed an elevated glucose levels then  administered antibiotics to the studied mice and the sweetener induced glucose intolerance disappeared. They then transplanted feces from saccharine treated mice into germ free mice and reproduced the same glucose intolerance effect. Furthermore, bacteria from mice not on artificial sweeteners were cultured in growth media to which saccharin was added. These bacteria were then transplanted into the intestines of germ free mice resulting in glucose intolerance.

The cause effect relationship between artificial sweeteners and diabetes development was very strong in this study. How exactly do gut bacteria affect glucose intolerance in humans is still not fully understood. One thing for sure however, millions of people who use Splenda and other similar products to prevent weight gain or control their diabetes are not helping themselves. Furthermore, hundreds of other artificial substances added to processed food may be working exactly the same way as saccharine and aspartane and driving the obesity numbers to epidemic levels. Finally, the low sugar “diet” products that flood the market are not exactly the best healthy alternative for you. Sugar free Jello and crystal light may be as deleterious as white sugar. Be careful for even zero calorie items can hurt you and whatever you pick from a tree or pluck from the ground is still the best food for your health!

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#### About Our Center
Houston Weight Loss Surgery Center, the office of Dr. Elias Darido, is dedicated to the treatment of Morbid Obesity. Dr. Darido’s goal is to provide an effective treatment for obesity based on the latest scientific discoveries in this field. Dr. Darido is renowned for his expertise in the surgical treatment of morbid obesity and diabetes. He has developed several innovative and minimally invasive surgical approaches for treatment of obesity and advanced type-two diabetes.
Our Mission
We aim to provide the most effective and safest weight loss solutions to all of our patients. Houston Weight Loss Surgery Center is committed to freeing you from the burden of obesity to live a long, happy and healthy life.
What sets us apart?
Houston Weight Loss Surgery Center, the office of Dr. Elias Darido, is dedicated to the treatment of Morbid Obesity. Dr. Darido’s goal is to provide safe, effective and durable solutions for your overweight problems. Dr. Darido is renowned for his expertise in minimally invasive surgery of morbid obesity and acid reflux. He has maintained an excellent safety record over the past 10 years with more than 1000 surgeries performed.
Most overweight patients struggle with daily heartburn, bloating and food regurgitation. Dr Darido addresses both issues, acid reflux and obesity, at the same time, during weight loss surgery. Packaged into one integrated system, our approach to fighting obesity is the most efficient, convenient and affordable in the healthcare industry in the Houston metropolitan area.
We focus on successful outcomes. Our unique weight loss surgery practice is specifically geared to meet your particular medical condition. You will not be left alone as our dedicated team will stay with you throughout your journey to ensure you get the best weight loss result.
What should you do next?
If you are ready for change, Houston Weight Loss Surgery Center can help you achieve things that you never imagined possible. Give us a call. A friendly specialist will greet you and help you take the first step towards a healthier you.
Consultation Request
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#### Accessibility
Houston Weight Loss Surgery Center is continuously working to improve the accessibility of content on our website. Below, you’ll find a few recommendations to help make your browsing experience more accessible:

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#### Comparison of Weight Loss Surgery Methods
Pros and cons of each type of weight loss surgery methods are outlined below. Dr. Darido will be happy to go over these in full detail at your initial consultation.

 

Gastric Bypass

Sleeve

Lap Band

Duodenal Switch (DS)

Success Rate

High
High
low
High

Invasivness 

Average
Average
Minimal
High

Hospital Stay

1 to 2 nights 
1 to 2 nights 
same day surgery
2 nights

Time off work

2 to 6 weeks
2 to 6 weeks
2 to 6 weeks
2 to 6 weeks

Gut Hormones 

Favorable change
Favorable change
no change
Favorable change

Hunger

Decreased
Decreased
Increased
Decreased

Foreign Objects

none
none
silicon band
none

Technical Complexity

less technically complex than DS
Simpler operation than a bypass
Lowest complexity
Highest complexity

Leak rate

less than 1%
less than 1 %
Almost zero
2 to 3%

Reversibility

Reversible
Irreversible
Reversible
Reversible

Vitamin Supplementation

life-long
life-long
life-long
life-long

Long-term complications

Internal Hernia or marginal ulcer
Almost none
Band erosion or slippage
Severe Nutrient and Vitamin defeciencies, ulceration, diarrhea

Overall Complication rate

< 1 %
< 1 %
< 1 %
2 to 4 %

Diabetes Resolution

Very Effective
Very Effective
Least Effective
Most Effective

#### Contact Us
Houston Weight Loss Surgeon – Dr. Elias Darido
Our team is standing by to help you verify your insurance coverage for weight loss surgery and to schedule your initial appointment with us.  Please complete the form to get started.
Address & Hours:
2100 W. Loop South, Suite 1115B
Houston, TX 77027
Monday through Fridays from 9 a.m. – 5 p.m. (By appointment)
(832) 963-1803
Travel & Accommodations
Patients traveling from outside Houston can get airport and hotel information here.
Request Consultation
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#### Cookie Policy
Cookie Policy

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#### Endoscopic Sleeve Gastroplasty
Non-Surgical Weight Loss Procedures
Non-surgical weight loss procedures are performed using endoscopy. The endoscope is a flexible camera tube inserted through the mouth and into the stomach. Endoscopic weight loss procedures aim at reducing stomach size leading to reduced meal size. Unfortunately, these purely restrictive procedures do not alter the hormones that control your appetite, hunger, and energy metabolism. Consequently, endoscopic weight loss procedures like Endoscopic Sleeve Gastroplasty and gastric balloon are not as effective as sleeve gastrectomy, the most commonly performed procedure in Houston.
Endoscopic Sleeve Gastroplasty
What is Endoscopic Sleeve Gastroplasty?
Endoscopic Sleeve Gastroplasty is a procedure that involves placing multiple sutures inside the stomach to reduce its size and limits food intake.
How is Endoscopic Sleeve Gastroplasty Performed?
The bariatric surgeon inserts an endoscope through the mouth fitted with a special device that allows suturing. Multiple sutures are placed inside the stomach to approximate the anterior and posterior walls and shrink stomach volume along its greater curvature.
Benefits of Endoscopic Sleeve Gastroplasty
Endoscopic Sleeve Gastroplasty requires no cuts and no dissection. It is an outpatient procedure performed under general anesthesia. The procedure is reversible. However, suture placement may create scar tissue between stomach and surrounding structures like the spleen. Revision sleeve gastroplasty to a sleeve gastrectomy may be complicated by scar tissue formation.
Preparing for Endoscopic Sleeve Gastroplasty
The first step is a consultation with Dr. Darido at Houston Weight Loss Surgery Center. During the consultation, Dr. Darido will go over important subjects related to weight gain, healthy eating, daily exercise, relevant metabolic diseases, different weight loss solutions, and expectations from Endoscopic Sleeve Gastroplasty.
Recovery from Endoscopic Sleeve Gastroplasty
Since the procedure is performed through the mouth and no incisions are made, recovery is very fast. You will go home the same day and you may be able to go back to work within few days after the procedure. You may develop nausea for around 2 weeks after the procedure.
How Much Does Endoscopic Sleeve Gastroplasty Cost?
Endoscopic Sleeve Gastroplasty is still considered investigational and it is not covered by insurance. The all-inclusive cost varies depending on where the procedure is performed. Financing options are also available.
Is Endoscopic Sleeve Gastroplasty Right for Me?
Endoscopic Sleeve Gastroplasty is not a Sleeve Gastrectomy, and therefore it is not a suitable option for everyone. At Houston Weight Loss Surgery Center we tailor the treatment to suit your particular condition. Dr. Darido is an avid researcher. He fully supports innovation in the field of bariatric and metabolic surgery and he devotes a good portion of his time developing novel weight loss procedures like Gastric Fundus Invagination. Endoscopic Sleeve Gastrolatry is a new weight loss procedure with no long-term outcome data. It is still considered investigational and not likely to produce durable and effective weight loss given the fact that it is purely a restrictive procedure. If you are interested in participating in a research study Dr. Darido may be able to help you.
Lets get started
EndoSleeve may be a good option for you. Contact Dr. Darido to determine if Endoscopic Sleeve Gastroplasty is the right choice for you.
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#### Endoscopic Weight Loss Procedures
Endoscopic Weight Loss Procedures
Non-surgical weight loss procedures are performed using endoscopy. The endoscope is a flexible camera tube inserted through the mouth and into the stomach. Endoscopic weight loss procedures aim at reducing stomach capacity leading to reduced meal size. Unfortunately, these purely restrictive procedures do not alter the hormones that control your appetite, hunger, and energy metabolism. Consequently, endoscopic weight loss procedures like Endoscopic Sleeve Gastroplasty and gastric balloon are not as effective as sleeve gastrectomy, the most commonly performed weight loss procedure in Houston.
Request Consultation
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#### Factors which may cause obesity
Factors contributing to obesity

Obesity is neither a cosmetic issue nor a psychological problem. It is very important for our patients to understand that obesity is a CHRONIC PROGRESSIVE MEDICAL DISEASE. Our understanding of obesity, energy metabolism and weight control has greatly evolved over the past few years. We now understand that many hormones control body weight and obesity is the result of an imbalance in these complex hormonal systems.
Therefore, obesity is no longer viewed as a consequence of over-eating, self-indulgence or lack of self-control. Rather, obesity is the result of multiple environmental and genetic factors that disrupt a variety of hormonal systems that control body weight and energy metabolism. The disruption of these hormones results in the progressive body fat accumulation.
It is important to know that diet and exercise, unlike weight loss surgery, are less likely to restore the underlying hormonal disruption that has led to obesity in the first place. Accordingly, overweight patients who loose excess weight by decreasing calorie intake, or increasing calorie expenditure through exercise, tend to regain their lost weight. This cyclical weight loss and regain also known as yo-yo diet is not only counterproductive but also harmful. It leads to frustration, disappointment and guilt feeling. Some studies have suggested increased risk of stroke and hypertension.
At Houston Weight Loss Surgery Center, we recommend changing your eating habits in a reasonable, realistic and intelligent fashion to avoid the yo-yo dieting effect. We emphasize to our patients the importance of changing what and when they eat before simply decreasing their total daily calorie intake.
In fact, not all calories are created equal and the first step towards healthy living and weight loss is eating clean food. Our patients are asked to stop completely all form of processed food like potato chips and candies. Throw away all sweets from your house. Sugar and white flour increase insulin resistance and result in weight gain. Therefore, we ask our patients to decrease their meal carbohydrate content while increasing their consumption of lean protein and good fats like avocados and nuts. Lean protein and healthy fats increase satiety, curb excessive appetite, and increase metabolism especially the setting of insulin resistance.
Once these recommendations are followed, patients are asked to start reducing their total daily caloric intake. Our patients are encouraged to keep a calorie count, pay attention to hunger cues, adopt intermittent fasting and avoid eating for comfort and out of boredom.

Other factors that may contribute to weight gain:
Medical conditions

Hypothyroidism
Cushings syndrome
Growth hormone deficiency
Polycystic ovarian disease
Prader – Willi syndrome
Leptin deficiency

Mental

Schizophrenia
Downs syndrome
Mental illness
Learning disabilities
Eating disorders

Physical Disability

Greatly reduced activity levels (eq. Wheelchair bound)
Reduction in exercise/Sedentary lifestyle

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#### Finance with Cherry
URL: https://houstonsleevesurgeon.com/finance-with-cherry/

#### Frequently Asked Questions
Weight Loss Surgery FAQ’s
Eating better and exercising (cardio), I haven’t lost any weight. Why?Exercise and Healthy eating are the best things you can do for your health. Daily physical activity can prolong your life and maintain your weight. However, when you are overweight, diet and exercise by themselves are not effective weight loss solutions. Medical studies have shown that obesity is a hormonal problem. Unless you address this hormonal imbalance it is very difficult to lose excess weight and maintain weight loss. When you diet, you increase your hunger and decrease your metabolism; you feel hungry all the time and you burn less calories. Consequently, it becomes very difficult to burn excess fat and loose weight. Today, the only effective solution to reversing your hormonal imbalance is weight loss surgery like gastric bypass or sleeve gastrectomy. Once you undergo surgery and loose weight, adopting a healthy eating pattern and a workout routine will allow you to maintain weight loss. Hope this helps.
When will I begin to loose weight after surgery?You will start loosing weight immediately following surgery. Weight loss will continue for approximately a year or two after which you reach a stable weight.
Does bariatric surgery affect pregnancy?Pregnancy should be avoided for 2 years after surgery during which you are experiencing rapid weight loss. Weight loss is associated with fertility improvement. Pregnancy and delivery complications significantly decrease after weight loss surgery.
Are there risks to bariatric surgery?Any surgery carries a certain risk. Dr. Darido makes sure to explain the risks and benefits of every bariatric procedure that he offers. Dr. Darido is very proud of his safety record in bariatric surgery and makes every effort possible to ensure you have a safe and pleasant experience at Houston Weight Loss Surgery Center.
How successful is surgery in eliminating excess weight?Weight loss surgery like sleeve gastrectomy and gastric bypass is very successful in eliminating excess weight. If you adopt a healthy lifestyle, studies indicate that long-term excess weight loss occurs in as many as 85% of patients
What type of exercise should I do?First rule in exercising: don’t hurt yourself. Don’t strain your joints and tear your muscles. Start by stretching and include flexibility training in your daily routine. After stretching, warm up your muscles and start with aerobic exercise. At the beginning you may only be able to do 10 mins at a time. Gradually your endurance will improve and you can exercise longer. Add resistance exercising to maintain and improve your muscle tone and mass. Avoid heavy lifting to prevent injury. Again always start with lower weights and gradually increase the intensity or length of your training.
For those who have joint pain swimming/water aerobic exercises are easy on the joints and highly recommended.
Why is fluid intake important?Following surgery your stomach size is small and you are unable to drink a full glass of water at once. If you don’t sip on water frequently throughout the day you may become dehydrated. Dehydration occurs when your body does not get enough fluid to keep it functioning at its best. Your body also requires fluid to burn its stored fat calories for energy. Carry a bottle of water with you all day, even when you are away from home; remind yourself to drink even if you don’t feel thirsty. Drinking 64 ounces of fluid is a good daily goal. You can tell if you’re getting enough fluid if you’re making clear, light-colored urine 5-10 times per day. Signs of dehydration can be thirst, headache, hard stools or dizziness upon sitting or standing up. You should contact our office if you are unable to drink enough fluid to stay hydrated.
How much protein do I need daily?60-80 grams of proteins are needed daily to maintain your muscle mass. During the period of rapid weight loss, in the first 6 months after surgery, your body needs a constant supply of dietary protein to prevent muscle mass wasting. Your body cannot absorb more than 30 grams of proteins at once. Try to include proteins in each meal. If you don’t provide enough protein in your diet, the body will take its protein from your muscles and you can become frail. Meats, eggs, dairy products, and beans are common protein sources in everyday foods. Protein extracts made from soy, brown rice and whey are commonly sold in stores. Protein shakes or bars may offer additional ways to meet your protein needs.
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#### Gastric Balloon
Non-Surgical Weight Loss
What is Endoscopic Intragastric Balloon?
Endoscopic Intragastric Balloon is a procedure that involves placement of a balloon made of silicone and filled with water into your stomach using endoscopy (through your mouth). The balloon limits the amount of food that you can eat at one time.

Benefits of Endoscopic Intragastric Balloon
The intragastric Balloon is NOT A SURGICAL PROCEDURE. Therefore, there are no cuts or incisions and no dissection on the inside of your body. The balloon can be removed at any point in time making the procedure completely reversible. NO BRIDGES are destroyed by placing the balloon. On the contrary, and especially in the super obese patient, the balloon can be placed to help reduce body weight in preparation for a more invasive metabolic procedure like the gastric bypass or gastric sleeve surgery.
How is Endoscopic Intragastric Balloon Performed?
Endoscopic Intragastric Balloon is performed by passing a silicone bag through your mouth and into your stomach where it is then filled with saline. This balloon floats freely within your stomach, taking up space and allowing you to feel full with smaller portions of food.
Preparing for Endoscopic Intragastric Balloon
The first step in balloon placement is a consultation with Dr. Darido at Houston Weight Loss Surgery Center. During the consultation, Dr. Darido will go over important subjects related to weight gain, healthy eating, daily exercise, relevant metabolic diseases, different weight loss solutions, and expectations from intragastric balloon placement. The second step, in preparation for your balloon placement, is a dietary consultation with our nutritionist with whom you will follow on a regular basis.
Recovery from Endoscopic Intragastric Balloon
Recovery from the Intragastric Balloon placement is fast and does not involve any downtime. You will go home the same day. Due to the balloon placement inside your stomach you may experience nausea, at times lasting up to 1 week or more.
How Much Does Endoscopic Intragastric Balloon Cost?
Endoscopic Intragastric Balloons are typically not covered by insurance, although we are happy to check your plan’s benefits FOR FREE. The all-inclusive cost is approximately $7,000. Financing options are also available.
Is Endoscopic Intragastric Balloon Right for Me?
Intragastric balloon is not for everyone. At Houston Weight Loss Surgery Center we tailor the treatment to suit your needs. If you are struggling to lose weight, but do not wish to undergo bariatric surgery or any procedure that modifies your anatomy, an Intragastric Balloon may be right for you. If you are preparing for an upcoming major event like a wedding or school reunion the intragastric balloon is a great option to shed some extra weight. If you want to loose the 30 pounds you gained during your last pregnancy the intragastric balloon may be your best option. You may also consider this procedure if you need to lose weight before having gastric bypass or Gastric Sleeve surgery especially if you are more than 400 pounds. Endoscopic Intragastric Balloon is typically recommended for patients with a BMI between 30 and 40.
What to Expect During Your Consultation for Endoscopic Intragastric Balloon
Dr. Darido will take his time to answer all of your questions and help you determine which bariatric procedure is right for you. He will discuss your medical history and your struggles with weight loss, as well as your long and short-term goals.
Lets get started
Endoscopic Intragastric Balloon is a great choice for many obese patients across the country who do not wish to undergo more invasive and permanent procedures. Contact Dr. Darido to determine if the endoscopic intragastric balloon is right for you.
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#### Gastric Balloon Booklet
Dr. Darido’s Approach To Gastric Balloon Placement and Management

Download Your FREE Copy Of Our Informational Booklet On Our Intragastric Balloon Program. In This Informative Guide, You Will Learn About:

Excess weight is a common problem
Houston Weight Loss Surgery Center IntraGastric Balloon Program
The ORBERA gastric balloon
Are you a candidate?
How is the Balloon Placed?
Living with the Intragastric Balloon
Cost and Insurance

Download your free booklet today!

#### Gastric Bypass Surgery
Gastric Bypass Surgery
Overview:
Gastric Bypass surgery also known as Roux-en-Y Gastric Bypass was initially developed in 1966. The procedure has stood the test of time and is now considered the gold standard of weight loss surgery.
How is gastric bypass surgery performed?
Gastric bypass is performed laparoscopically (through tiny incisions). The surgery involves creating a small gastric pouch the size of a golf ball. The intestines are then cut and attached to the small pouch. As a result most of the stomach and proximal intestines are bypassed leading to hormonal changes that promote weight loss. Since the intestines are re-routed, there is a small long-term risk of internal hernia or marginal ulcer formation.
How does gastric bypass work?
Roux-en-Y gastric bypass is a restrictive and metabolic procedure. The size of your gastric pouch is very small hence your meal size is no more than half a cup. However, restriction alone is not enough for long-term weight loss. Gastric bypass surgery curbs your hunger, increases satiety, decreases food cravings and boosts your metabolism. As a result, you eat less but burn more calories leading to significant weight loss.
Is gastric bypass surgery a good option for me?
Many factors are taken into consideration when deciding whether or not you are a good candidate for gastric bypass. After thorough assessment and physical examination, Dr. Darido will discuss the different options available for successful weight loss. Then you and Dr. Darido will agree on the best treatment strategy to adopt.
How much does gastric bypass surgery cost?
Surgery cost varies depending on your insurance plan. Our insurance and finance specialists are available to answer all your financial questions.
What is my recovery time?
You will usually spend a night or two in the hospital after surgery. It takes around 10 days before you can go back to work.
Lets get started
Gastric bypass surgery is an effective weight loss solution. If you are looking to loose weight and want to find if gastric bypass is good for you please contact our office for a private consultation.
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#### Gastric Sleeve Revision Surgery
Gastric Sleeve Revision Surgery Overview
Gastric sleeve surgery is currently the most commonly performed weight loss procedure in Houston, TX. When properly performed, Sleeve surgery results in significant and durable weight loss with minimal short-term and long-term complications. Proper sleeve surgery results in a banana shaped stomach with no twisting, narrowing or retained gastric fundus. The gastric fundus is the upper part of the stomach that stores ingested food, control gastric emptying, and secretes many hormones that affect appetite, hunger and energy metabolism. A retained gastric fundus following a poorly performed sleeve surgery results in poor weight loss and the development of GERD (gastroesophageal reflux disease). GERD also known as acid reflux results in heartburn, cough and food regurgitation. New onset GERD following sleeve surgery is a strong indication of a poorly performed gastric sleeve surgery.
When is Gastric Sleeve revision surgery performed?
If you had a gastric sleeve procedure and you are currently experiencing poor weight loss, or any GERD related symptom like chronic cough, heartburn, and food regurgitation please give us a call. Do not treat yourself with over the counter antacid medications. You need to be thoroughly evaluated by a heartburn and weight loss specialist. If you are found to have an incompletely resected gastric sleeve, or a narrowed sleeve lumen, revision surgery may be offered to amend the problem.
How does Gastric Sleeve revision surgery work?
A revision surgery is indicated following gastric sleeve to correct certain anatomic problems that are causing acid reflux related symptoms and poor weight loss. The most common gastric sleeve revision procedure performed at Houston Weight Loss Surgery Center and Houston Heartburn and reflux center is hiatal hernia repair and resection of retained gastric fundus. A hiatal hernia occurs when the upper part of the stomach migrates into the chest through an enlarged opening in the breathing muscle.  This results in significant weakness in the lower esophageal sphincter leading to bothersome acid reflux and bile gastritis following gastric sleeve surgery.
Is Gastric Sleeve revision a good option for me?
Revision surgery is a complicated procedure and many factors are taken into consideration when evaluating a bariatric patient for potential revision surgery. After thorough assessment, Dr. Darido will discuss with you and at length the best treatment options for you. When indicated, a revision sleeve procedure allows you to alleviate your acid reflux and put you back on the right path for weight loss and healthy life.
Who should perform your Sleeve revision surgery?
It is extremely important to choose a knowledgeable weight loss and heartburn doctor to perform your sleeve revision surgery. Why? Poor weight loss and acid reflux go hand in hand most often following incomplete gastric sleeve resection and poor hiatal hernia repair. A specialist in both fields of acid reflux disease and weight loss, like Dr. Darido, is the most qualified doctor to take good care of you.
How much does sleeve surgery cost?
Surgery cost varies depending on your insurance plan. Our insurance and finance specialists are available to answer all your financial questions.
What is my recovery time?
You will usually spend a night or two in the hospital after surgery. It takes around one week before you can go back to work.
Lets get started
If you would like to learn more about sleeve revision surgery, we encourage you to contact our office for a private consultation. During this relaxed and informative session, you will get to meet Dr. Darido and learn if you are a good candidate for revision surgery.
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#### Gastric Sleeve Surgery
Houston Gastric Sleeve Surgery (also known as Sleeve Gastrectomy)
Overview:
Gastric Sleeve surgery is currently the most commonly performed weight loss procedure in Houston. Gastric Sleeve surgery has gained great popularity over the past few years because of its effectiveness and simplicity.
How is gastric sleeve surgery performed?
Gastric Sleeve surgery is performed laparoscopically (through tiny incisions). The surgery involves transecting 85% of the stomach. The intestines are not re-routed (like gastric bypass surgery). As a result, there is no risk of internal hernia or marginal ulcer formation. This makes the sleeve almost risk free on the long run. The lack of long-term side effects is a major advantage for sleeve gastrectomy when compared to gastric bypass and duodenal switch surgery.
How does the sleeve work?
Gastric Sleeve surgery is a restrictive and metabolic procedure. The volume of gastric sleeve is very small hence your meal size is no more than half to one full cup. However, restriction alone is not enough for weight loss. Sleeve surgery curbs your hunger, decreases food cravings and boosts your metabolism. This is secondary to hormonal changes like ghrelin also known as the hunger hormone.
Is gastric sleeve surgery a good option for me?
Many factors are taken into consideration when deciding whether or not you are a good candidate for gastric sleeve surgery. After thorough assessment and physical examination, Dr. Darido will discuss the various treatment options that will be of benefit to you. Around 70% of our patients qualify for gastric sleeve surgery.
Who should perform your gastric sleeve in Houston?
It is extremely important to choose a knowledgeable bariatric and acid reflux surgeon to perform your sleeve gastrectomy. Why? Incomplete gastric resection results in inadequate weight loss. The most important aspect of gastric sleeve surgery is the resection of the ballooning part of the stomach also called gastric fundus. The gastric fundus is that part of the stomach that stretches to accommodate an ingested meal. The gastric fundus also secretes the hunger hormone called Ghrelin. Incomplete gastric fundus resection will not result in the restriction and hormone change needed to achieve adequate weight loss. Furthermore, most overweight patients have acid reflux due to hiatal hernia. Hiatal hernia occurs when upper part of stomach or gastric fundus moves up into the chest from its normal abdominal location. Hiatal hernia repair must be performed at the same time as sleeve gastrectomy to prevent severe acid reflux after weight loss surgery.
How much does Houston gastric sleeve surgery cost?
Surgery cost varies depending on your insurance plan. Our insurance and finance specialists are available to answer all your financial questions.
What is my recovery time?
You will usually spend a night or two in the hospital after surgery. It takes around 10 days before you can go back to work.
Lets get started
If you would like to learn more about sleeve surgery, we encourage you to contact our office for a private consultation. During this relaxed and informative session, you will get to meet Dr. Darido and learn whether gastric sleeve surgery can work for you.
Sleeve Gastrectomy for Weight Loss
An article by the Journal of the American Medical Association (Click Here)
Request Consultation
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Houston’s Premier Gastric Sleeve SurgeonTransforming Lives Through Gastric Sleeve Surgery.
START YOUR JOURNEYHouston Weight Loss and Sleeve Surgery Center, the office of Dr. Elias Darido, is a leading provider of safe and reliable weight loss solutions in the Houston area.
Why Choose Us?

Strong Safety Record

Minimally Invasive Surgery

Home Same Day

Proven Weight Loss Results

Hiatal Hernia Repair Included

High Patient Satisfaction

Competitive pricing

Free Insurance Check

Financing Available 

Consultation & Insurance Check!

Houston Sleeve Surgery
Dr. Darido specializes in a wide range of weight loss surgeries including gastric bypass, gastric sleeve surgery and lap band conversion to bypass or gastric sleeve surgery. Dr. Darido is especially focused on the upper part of the stomach also called gastric fundus. Learn about Sleeve Gastrectomy
What Sets Us Apart
Our unique weight loss surgery practice revolves around providing effective and safe weight loss solutions. Our focus on successful outcomes is specifically geared for your unique medical condition. Learn more about our weight loss center
Meet Dr. Elias Darido
Effective, safe and durable weight loss treatment solutions“ is the vision of Dr. Elias Darido, founder and chief surgeon of Houston Weight Loss Surgery Center. In today’s healthcare environment, many overweight patients are falling victims to fad diets, fake pills and false promises.  Meet Dr. Darido
Are You a Candidate?
There are many factors that determine whether weight loss surgery is right for you. One of the main criteria is having a BMI of over 35 as well as other indicators such as type II diabetes, hypertension, sleep apnea and other respiratory disorders.  See if you’re a candidate for weight loss surgery
Insurance Accepted
Insurance coverage for weight loss surgery depends on the plan you have chosen, including specific coverage options in your policy and your employer’s health plan. Houston Weight Loss Surgery Center has a dedicated insurance specialist who can help you. Using insurance to cover your weight loss surgery
Your Weight Loss Journey
The health care team at Houston Weight Loss Surgery Center is committed to making your weight loss journey as smooth as possible. Your weight loss journey begins at the Houston Weight Loss Center
Our patients say it best!
We’re appreciative of our patient testimonials!  See all reviews here.
	
		
								
			
	
		
								
			
	
		
								
			
	
		
								
			
	
		
								
			
	
		
								
			
	
		
								
			
	
		
								
			
Houston Weight Loss Blog
	
		
							
						Heartburn After VSG24th November 2025		
			
	
		
							
						Going from Sleeve to Bypass: How Much Weight Do You Lose?15th October 2025		
			
	
		
							
						Robotic Gastric Sleeve Surgery6th October 2025		
			
	
		
			
		
	
				
				
					
				
				
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[rev_slider_vc alias="Home1"]Houston Weight Loss Surgery Center, the office of Dr. Elias Darido, is a leading provider of comprehensive weight loss solutions in the greater Houston area.
Request a FREE Insurance check!
Complete the short form below and a member of our insurance team will contact you to verify your insurance coverage for weight loss surgery.
   
 
  
 
[vc_empty_space height="15px"]Dr. Elias Darido discusses the relationship between excess weight and acid reflux disease during a recent segment of Great Day Houston with Deborah Duncan
Watch a recent segment of Great Day Houston, where Dr. Darido explains the approach to acid reflux disease in overweight patients interested in bariatric surgery.
[vc_single_image image="448" img_size="full" style="vc_box_rounded"]Meet Dr. Elias Darido
Effective, safe and durable weight loss treatment solutions“ is the vision of Dr. Elias Darido, founder and chief surgeon of Houston Weight Loss Surgery Center. In today’s healthcare environment, many overweight patients are falling victims to fad diets, fake pills and false promises.  Meet Houston Sleeve Surgeon, Dr. Elias Darido
[vc_single_image image="445" img_size="900x800" style="vc_box_rounded"]What Sets Us Apart
Our unique weight loss surgery practice revolves around providing effective and safe weight loss solutions. Our focus on successful outcomes is specifically geared for your unique medical condition. Learn more about our weight loss center
[vc_single_image image="444" img_size="900x800" style="vc_box_rounded"]Sleeve Gastrectomy
Dr. Darido specializes in a wide range of weight loss surgeries including gastric bypass, sleeve gastrectomy and lap band conversion to bypass or sleeve. Dr. Darido is especially focused on the upper part of the stomach also called gastric fundus. Learn about Sleeve Gastrectomy
[vc_single_image image="466" img_size="full" style="vc_box_rounded"]Are You a Candidate?
The are many factors that determine whether weight loss surgery is right for you. One of the main criteria is having a BMI of over 35 as well as other indicators such as type II diabetes, hypertension, sleep apnea and other respiratory disorders.  See if you’re a candidate for weight loss surgery
[vc_single_image image="468" img_size="900x800" style="vc_box_rounded"]Insurance Accepted
Insurance coverage for weight loss surgery depends on the plan you have chosen, including specific coverage options in your policy and your employer’s health plan. Houston Weight Loss Surgery Center has a dedicated insurance specialist who can help you. Using insurance to cover your weight loss surgery
[vc_single_image image="470" img_size="900x800" style="vc_box_rounded"]Your Weight Loss Journey
The health care team at Houston Weight Loss Surgery Center is committed to making your weight loss journey as smooth as possible. Your weight loss journey begins at the Houston Weight Loss Center
Our patients say it best!
We’re appreciative of our patient testimonials!  See all reviews here.
Individual results may vary
Individual results may vary
Houston Weight Loss Blog
Visit our blog
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#### Houston Weight Loss Surgery Blog
Heartburn After VSG24th November 2025		
			
	
		
						Going from Sleeve to Bypass: How Much Weight Do You Lose?15th October 2025		
			
	
		
						Robotic Gastric Sleeve Surgery6th October 2025		
			
	
		
						Optimizing Weight Loss After Sleeve Gastrectomy12th September 2025		
			
	
		
						Twisted Gastric Sleeve28th May 2025		
			
	
		
						Insulin Resistance, Pre-Diabetes, and Sleeve Gastrectomy10th March 2025		
			
	
		
						Is Mounjaro Exacerbating Your Food Regurgitation?18th June 2024		
			
	
		
						Mounjaro Is Not Helping Me Lose Weight16th June 2024		
			
	
		
						The Perfect Sleeve Gastrectomy to Prevent GERD23rd March 2024		
			
	
		
						When Can I stop Mounjaro and Ozempic?24th July 2023		
			
	
		
						Heartburn and Acid Reflux with Weight Regain after VSG20th July 2023		
			
	
		
						ESG or Once Weekly Injection for Treatment of Obesity20th May 2023		
			
	
		
						Is ESV Indicated for VSG Revision?11th February 2023		
			
	
		
						Mounjaro or Endosleeve for Weight Loss?17th January 2023		
			
	
		
						Manga Gastrica en Houston | Gastric Sleeve in Houston28th November 2022		
			
	
		
						Weight Loss Around Thanksgiving22nd November 2022		
			
	
		
						Orbera vs Ozempic for Weight Loss21st November 2022		
			
	
		
						Heartburn Treatment Following Sleeve Gastrectomy23rd May 2022		
			
	
		
						Persistent Heartburn Following Sleeve to Bypass Conversion20th October 2021		
			
	
		
						Can I lose Too Much Weight After Gastric Sleeve Surgery?24th August 2021		
			
	
		
						Best Sleeve Surgery in Houston30th July 2021		
			
	
		
						I Never Had Reflux Before My Gastric Sleeve.15th May 2021		
			
	
		
						Do Hiatal Hernias Fail After Gastric Sleeve Surgery?13th April 2021		
			
	
		
						Cough after Gastric Sleeve Surgery22nd March 2021		
			
	
		
						Weight Loss after Gastric Sleeve to Bypass Conversion30th January 2021		
			
	
		
						Gastric Sleeve: Where You Go First Matters25th November 2020		
			
	
		
						Heartburn After Sleeve Gastrectomy30th October 2020		
			
	
		
						Gastric Emptying after Sleeve Gastrectomy7th October 2020		
			
	
		
						Heartburn after Gastric Sleeve Surgery in Dallas16th September 2020		
			
	
		
						Gastroparesis after Nissen Fundoplication27th August 2020		
			
	
		
						Gastric Sleeve Surgery after Heller Myotomy17th July 2020		
			
	
		
						Late Onset GERD after Sleeve Gastrectomy6th July 2020		
			
	
		
						Persistent Heartburn after Gastric Sleeve to Bypass Conversion23rd June 2020		
			
	
		
						Gastric Sleeve or Bypass after Nissen Fundoplication9th June 2020		
			
	
		
						Bile gastritis after Sleeve Gastrectomy20th May 2020		
			
	
		
						Lap Band and Esophageal Damage14th May 2020		
			
	
		
						Gastric bypass, Gastroparesis, Sleeve Gastrectomy20th April 2020		
			
	
		
						Gastric bypass, Gastroparesis, Sleeve Gastrectomy21st March 2020		
			
	
		
						Should You Check for Hiatal Hernia before Sleeve Gastrectomy?14th March 2020		
			
	
		
						Sleeve Gastrectomy for BMI less than 35: Is it Worth it?22nd February 2020		
			
	
		
						Gastric bypass, Gastroparesis, Sleeve Gastrectomy12th February 2020		
			
	
		
						Difficulty Swallowing after Gastric Sleeve Surgery1st February 2020		
			
	
		
						Is Barrett’s Esophagus a Contraindication for Sleeve Gastrectomy?28th January 2020		
			
	
		
						Houston Bariatric Surgery2nd January 2020		
			
	
		
						Intermittent Fasting: Beyond Weight Loss30th December 2019		
			
	
		
						The Dumbbell Gastric Sleeve: A Recipe for Heartburn29th November 2019		
			
	
		
						Sleeve Gastrectomy in Patients with Previous Nissen fundoplication5th November 2019		
			
	
		
						Pyloric Drainage and Gastroparesis18th September 2019		
			
	
		
						The Ketogenic Diet for Obesity and Diabetes2nd September 2019		
			
	
		
						Duodeno-gastric Bile Reflux after Sleeve Gastrectomy5th August 2019		
			
	
		
						Gastric Sleeve Migration in Weight loss Surgery16th July 2019		
			
	
		
						Endoscopic Sleeve Gastroplasty Under Fire12th July 2019		
			
	
		
						Weight Regain after Bariatric Surgery21st June 2019		
			
	
		
						Is Mini Gastric Bypass a Safe Option for Weight Loss?10th June 2019		
			
	
		
						Processed food and Weight Gain after Gastric Sleeve20th May 2019		
			
	
		
						Is Your Gastric Sleeve Dilated?11th April 2019		
			
	
		
						Single Incision Gastric Sleeve Surgery30th January 2019		
			
	
		
						Gastric Sleeve Surgery and Type 2 Diabetes9th January 2019		
			
	
		
						New Year, New Resolution: Take control of Your Appetite3rd January 2019		
			
	
		
						Sleeve Gastrectomy Technique: Does It matter?13th December 2018		
			
	
		
						Gastric Sleeve Revision Surgery in Houston13th November 2018		
			
	
		
						Is Sleeve Gastrectomy the Best Gastroplasty for Weight Loss?2nd November 2018		
			
	
		
						Does Gastric Sleeve Surgery Cause Barrett’s Esophagus?21st October 2018		
			
	
		
						Insufficient Weight Loss after Gastric Sleeve Surgery15th October 2018		
			
	
		
						Intermittent Fasting and Weight Loss10th October 2018		
			
	
		
						Gastric Bypass and Sleeve Gastrectomy Revision Surgery2nd October 2018		
			
	
		
						Question of the Week: G-POEM for Gastroparesis30th September 2018		
			
	
		
						Is Keto Safe?18th September 2018		
			
	
		
						A Bariatric Surgeon Perspective on Keto Diet21st August 2018		
			
	
		
						Acid Reflux, Sleeve Gastrectomy, Gastric Bypass29th July 2018		
			
	
		
						How Does Bariatric Surgery Work? A New Review Article17th July 2018		
			
	
		
						Nissen-Sleeve operation, is it an option?4th June 2018		
			
	
		
						Is Pyloroplasty a Reasonable Solution for Gastroparesis?9th May 2018		
			
	
		
						Is Food Consumption Changing in the US?4th March 2018		
			
	
		
						Gastric Bypass Long-term Complications22nd January 2018		
			
	
		
						JAMA Obesity Theme Issue: Gastric Sleeve Surgery Is Here to Stay18th January 2018		
			
	
		
						Best Diet for 20185th January 2018		
			
	
		
						Modern Economics Has Given Us Abundance and Obesity26th December 2017		
			
	
		
						Gastric Sleeve Surgery and GERD12th December 2017		
			
	
		
						How Do I Manage Advanced Gastroduodenoparesis?7th December 2017		
			
	
		
						Question of the week: What Would You Do for This Gastroparesis Case?4th December 2017		
			
	
		
						Holiday Meals Still Matter1st December 2017		
			
	
		
						Persistent Gastroparesis Following Gastric Sleeve Surgery10th November 2017		
			
	
		
						Obesity, Metabolism and the Circadian Rhythm9th October 2017		
			
	
		
						Gastric Pouch Emptying Following Gastric Bypass Surgery23rd September 2017		
			
	
		
						Question of the Week from Tina21st September 2017		
			
	
		
						Case of the week: Gastric Sleeve Surgery Following Nissen Fundoplication15th September 2017		
			
	
		
						Rossetti Sleeve Gastrectomy4th September 2017		
			
	
		
						Hurricane Harvey: Together We Heal2nd September 2017		
			
	
		
						Do UGIs Predict Weight Loss after Sleeve Gastrectomy?28th August 2017		
			
	
		
						The Elipse Balloon: A new gastric Balloon with Interesting Features23rd August 2017		
			
	
		
						Lap Band Long-term Outcome: A New Study from Switzerland23rd August 2017		
			
	
		
						A New FDA Warning Regarding Gastric Balloons22nd August 2017		
			
	
		
						Obesity in America21st August 2017		
			
	
		
						Gastric Pouch Emptying of Solid Food in Gastric Bypass Patients20th August 2017		
			
	
		
						Question of the week: Sleeve surgery after Fundoplication surgery7th August 2017		
			
	
		
						Laparoscopic Treatment of Gastroparesis: A Single Center Experience3rd August 2017		
			
	
		
						G-POEM for Gastroparesis Treatment14th July 2017		
			
	
		
						The Effect of Dietary Fat on the Hypothalamus11th July 2017		
			
	
		
						Adjustable Gastric Band Reoperation Cost3rd July 2017		
			
	
		
						Do We Have a Cure for Gastroparesis?26th June 2017		
			
	
		
						What Exactly Is the Magenstrasse?12th June 2017		
			
	
		
						Case of The Week: Lap Band and Pseudo-achalasia30th May 2017		
			
	
		
						Long-Term Outcomes of Lap Band Surgery: The Big Lesson22nd May 2017		
			
	
		
						A Stomach Road or ‘‘Magenstrasse’’ for Weight Loss15th May 2017		
			
	
		
						Do You Suffer from Acid Reflux Following Sleeve Gastrectomy?8th May 2017		
			
	
		
						The Hairpin Sleeve Gastrectomy28th April 2017		
			
	
		
						Single Incision Sleeve Gastrectomy25th April 2017		
			
	
		
						Sleeve Gastrectomy and Increased Intra-Gastric Pressure17th April 2017		
			
	
		
						Gastric Electric Activity and Sleeve Gastrectomy12th April 2017		
			
	
		
						Morbid Obesity, GERD, Gastroparesis and Type 2 Diabetes: What Do They Have in Common?10th April 2017		
			
	
		
						Who Would Have Thought About It: Gastric Balloon and Pancreatitis?4th April 2017		
			
	
		
						Question of The Week: Acid Reflux Following Sleeve3rd April 2017		
			
	
		
						SAGES Meeting 2017: GERD and Obesity28th March 2017		
			
	
		
						Hiatal Hernia Repair During Sleeve Gastrectomy Is Safe and Feasible20th March 2017		
			
	
		
						Bariatric Surgery and Esophageal Adenocarcinoma15th March 2017		
			
	
		
						Sleeve Gastrectomy, GLP-1 Secretion and Gastric Emptying6th March 2017		
			
	
		
						Continuous belching following gastric sleeve surgery27th February 2017		
			
	
		
						Gastric Bypass Surgery Is Not a Good Option for Gastroparesis22nd February 2017		
			
	
		
						Demystifying the Role of Weight Loss Surgery14th February 2017		
			
	
		
						Is Weight Loss Surgery a Good Option for Achalasia Patients?6th February 2017		
			
	
		
						Endoscopic Bariatric Surgery Revision in Houston31st January 2017		
			
	
		
						Patient Education: Gastric Balloon and Portion Control20th January 2017		
			
	
		
						Public Service Announcement from the American Society for Metabolic and Bariatric Surgery (ASMBS)18th January 2017		
			
	
		
						Heart Health for 201715th January 2017		
			
	
		
						Jimmy’s Success Story Could be Yours in 20179th January 2017		
			
	
		
						Lap Band, Achalasia, and Severe Esophagitis6th January 2017		
			
	
		
						Holiday Weight Gain: Now What?3rd January 2017		
			
	
		
						Question about Nissen Fundoplication30th December 2016		
			
	
		
						Question of the Month27th December 2016		
			
	
		
						One Stage Gastric Band Removal and Conversion to Gastric Sleeve21st December 2016		
			
	
		
						The Nissen Sleeve Operation: A New Take on the Gastric Sleeve20th December 2016		
			
	
		
						What Type of Exercise Is Good for You?14th December 2016		
			
	
		
						The Key to Health and Longevity: An Anti-Inflammatory Diet7th December 2016		
			
	
		
						The GLP-1 Debate31st October 2016		
			
	
		
						Are You an Early Adopter of Endobariatric Surgery?19th October 2016		
			
	
		
						The Case for Gastric Sleeve Surgery for Treatment of Diabetes30th September 2016		
			
	
		
						The Clues to the Causative Etiologies of Type 2 Diabetes22nd September 2016		
			
	
		
						Modified Gastric Sleeve Surgery for Treatment of Gastroparesis19th September 2016		
			
	
		
						Gastric Sleeve Volume: Does It Affect Weight Loss?16th September 2016		
			
	
		
						Post-Sleeve GERD As A Weight Loss Predictor12th September 2016		
			
	
		
						Bariatric Surgery Weight Loss Outcome at VA Medical Centers10th September 2016		
			
	
		
						Gastric Band Conversion to Sleeve Gastrectomy6th September 2016		
			
	
		
						Gastric Leptin and The Feeling of Fullness after Metabolic Surgery?5th September 2016		
			
	
		
						Staying Hydrated in Houston Summer Heat31st August 2016		
			
	
		
						Bile Gastritis Following Gastric Sleeve Surgery31st August 2016		
			
	
		
						The Next Big Thing: What Is Driving Research In Bariatric, Metabolic and Foregut Surgery?16th August 2016		
			
	
		
						Parsley: A Vibrant Vegetable with Tremendous Health Benefits15th August 2016		
			
	
		
						The Gastric Fundus and Lap Band Removal12th August 2016		
			
	
		
						Houston Weight Loss Surgery Center Recommends Dark Chocolate8th August 2016		
			
	
		
						The Modern Bariatric Surgeon3rd August 2016		
			
	
		
						Case of the Week: Sleeve in the Setting of a Large Hiatal Hernia1st August 2016		
			
	
		
						Overweight and Suffering from Heartburn? We Can Help.27th July 2016		
			
	
		
						Understanding Gut Electrical Activity22nd July 2016		
			
	
		
						Pokemon Go: Get Up and Go19th July 2016		
			
	
		
						Staple line Reinforcement, Distance From Antrum and Bougie Size: A New Study From MBSAQIP19th July 2016		
			
	
		
						Walking In Houston: We May Have A Problem14th July 2016		
			
	
		
						Lap Band Mechanism of Action and The Vagus Nerve5th July 2016		
			
	
		
						What In The World?23rd June 2016		
			
	
		
						Hispanics Undergoing Bariatric Surgery: A New Study6th June 2016		
			
	
		
						Gastric Sleeve Surgery, De Novo Acid Reflux and Medical Tourism24th May 2016		
			
	
		
						The Biggest Loser: Struggling To Keep Weight Off20th May 2016		
			
	
		
						Insurance-mandated medical weight management before bariatric surgery13th May 2016		
			
	
		
						Endoscopic Sleeve Gastroplasty3rd May 2016		
			
	
		
						Behavior, Biology and Bariatric Surgery Outcomes25th April 2016		
			
	
		
						Zero Calorie Artificial Sweeteners Cause Diabetes and Obesity17th April 2016		
			
	
		
						Is Gastric Sleeve Surgery The Right Choice For Me?11th April 2016		
			
	
		
						For The First Time In Human History: Obesity Rates Trump Underweight Numbers In A Worldwide Analysis6th April 2016		
			
	
		
						Gastric Sleeve Surgery and Hiatal Hernia: Repair or Not?28th March 2016		
			
	
		
						Intermittent Vagal Nerve Blockade For Morbid Obesity18th March 2016		
			
	
		
						Meatless Diet In Houston, TX25th February 2016		
			
	
		
						From Bariatric to Metabolic Surgery… A Field in Evolution15th February 2016		
			
	
		
						Eatfitters: Fresh Food Cooked Daily11th February 2016		
			
	
		
						Overeating doesn’t make you fat. The Process of Getting Fat Makes You Overeat4th February 2016		
			
	
		
						Interesting Case: Severe Acid Reflux After Gastric Sleeve Surgery?27th January 2016		
			
	
		
						Weight Loss and Health Wearables16th January 2016		
			
	
		
						Acid Reflux Disease In Patients presenting For Bariatric Surgery: A Whole Different Ballgame31st December 2015		
			
	
		
						Holiday Eating Tips From Houston Weight Loss Surgery Center24th December 2015		
			
	
		
						Best Treatment for Gastroparesis: Gastric Bypass or Gastric Sleeve?22nd December 2015		
			
	
		
						Obesity and GERD: Weight loss surgery options1st December 2015		
			
	
		
						The rise of Gastric Sleeve procedure for weight loss24th November 2015		
			
	
		
						Not All Calories Are Created Equal6th November 2015		
			
	
		
						Restaurants and mindful eating3rd November 2015		
			
	
		
						The Harmful Effects of Sugar2nd November 2015		
			
	
		
						Fall in Love… with Vegetables26th October 2015		
			
	
		
						In Defense of Food7th October 2015		
			
	
		
						The 12th Annual Bariatric Summit (Austin Texas, 2015 )28th September 2015		
			
	
		
						Get Involved With Your Food15th September 2015		
			
	
		
						Houston Weight Loss Surgery Center recommends: Bariatric Pizza10th September 2015		
			
	
		
						Understanding The Biology of Obesity: Adipocyte Browning8th September 2015		
			
	
		
						Pre-Op Liver Reduction Diet5th September 2015		
			
	
		
						Let Food Be Thy Medicine: Bone Broth26th August 2015		
			
	
		
						Protein Shake Recipes To Support Your Recovery After Sleeve Surgery24th August 2015		
			
	
		
						Why Diet Before Weight Loss Surgery?21st August 2015		
			
	
		
						The FDA Approves A New Device For Weight Loss: Reshape Dual Balloon31st July 2015		
			
	
		
						Coping with Stress24th July 2015		
			
	
		
						Can Gastric Bypass Surgery Survive the Assault of Cheese Crackers?19th July 2015		
			
	
		
						A New Science On The Horizon: Your Gut Bacteria6th July 2015		
			
	
		
						Are you drinking enough water this summer in Houston?27th June 2015		
			
	
		
						Is Sleeve surgery a good option for patients with heartburn?19th June 2015		
			
	
		
						Houston, we have a weight loss problem?17th June 2015		
			
	
		
						Is your lack of sleep causing weight gain?8th June 2015		
			
	
		
						Diets and lifestyle changes that speed up your metabolism5th June 2015		
			
	
		
						What is Mindful Eating?2nd June 2015		
			
	
		
						What is hunger?28th May 2015		
			
	
		
						Is your lap band causing you heartburn?26th May 2015		
			
	
		
						What is Gastric Plication?22nd May 2015		
			
	
		
						Control your portion size and stop weight gain20th May 2015		
			
	
		
						Causes of Obesity1st May 2015		
			
	
		
						What Does Healthy Eating Mean?1st May 2015		
			
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[vc_wp_posts number="5"][vc_wp_categories options="count"]

#### Insurance and Financing Options
Does insurance cover weight loss surgery?

Insurance coverage for bariatric surgery depend on the plan you have chosen, including specific coverage options in your policy and your employer’s health plan. Gastric sleeve surgery is the most commonly performed weight loss procedure in Houston and gastric sleeve surgery cost is the most common question we receive. Houston Weight Loss Surgery Center has a dedicated insurance specialist who can help you and answer all your financial questions.
We have been successful in helping many obtain insurance approval who were previously unable to do so. To find out if your insurance provider covers weight loss surgery, please contact us at 832-963-1803 or fill the form on this page and a member of our staff will contact you shortly.
The self-pay cost for Gastric Sleeve Surgery in Houston ranges from $12,000 to $16,000 depending on the hospital and your length of stay. At Houston Weight Loss Surgery Center, we offer sleeve gastrectomy at $12,900 including a one night hospital stay. After gastric sleeve surgery, you do not require frequent follow-up visits for adjustments like Lap Band patients. Furthermore, regular post-operative follow up is free.
Additional costs to consider include nutritional supplements like protein powder and vitamins. Some patients may require cosmetic surgery to remove excess skin. We typically recommend body contouring 2 years after surgery, at which point body weight will stabilize. Cosmetic surgery may be covered by insurance, depending on your plan.
Do you offer financing options for weight loss surgery?
Yes, we offer convenient financing through these companies:
Cherry

Prosper Healthcare

Care Credit

*Subject to credit approval. Minimum monthly payments required. Visit www.carecredit.com for details.
United Medical Credit

Insurance Check
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#### Lap Band Revision Surgery
Lap Band Revision Surgery
Overview:
Lap band revision surgery is currently the most commonly performed revision weight loss procedure. Several years ago, adjustable gastric banding also known as lap band procedure was very common. It was marketed as safe, effective and minimally invasive. Unfortunately, the majority of Lap Band patients failed to loose weight. Many of them were over-restricted in hopeless attempts at promoting weight loss. Esophageal over-restriction resulted in heartburn, food regurgitation, daily vomiting, chronic cough and nighttime symptoms causing aspiration pneumonia.
When is Lap Band revision surgery performed?
All Lap band patients need to follow up on a regular basis with an experienced bariatric surgeon. At Houston Weight Loss Surgery Center, we don’t think that a nurse practitioner is qualified to deal with band adjustments. If you have a Lap band and have not lost your excess weight please give us a call. If you have a Lap Band and you suffer from heartburn, food regurgitation, inability to tolerated regular diet, vomiting, pain, daily cough and nighttime symptoms please get evaluated by a heartburn and acid reflux specialist (www.houstonheartburn.com). Do not take antacid medications to treat your heartburn in the setting of Lap Band. Do not Take cough medications to treat your daily cough in the setting of a Lap Band. Don’t mask your symptoms. Treat the underlying cause. Your band may be too tight. In some instances the band may slip or erode. Following thorough evaluation, your experienced weight loss surgeon may decide to remove the band to alleviate your symptoms and prevent further damage to the esophagus. Additional surgeries may be required to eliminate your symptoms or promote weight loss.
How does Lap Band revision surgery work?
Lap Band removal is indicated to alleviate over-restriction symptoms and prevent further damage to esophageal motility. By removing the obstruction esophageal motility recovers and symptoms resolve. Sometimes, the damage is irreversible. In these cases, band removal alone is not enough. Additional surgeries are needed to fix the problem. Most commonly the band causes a hiatal hernia to form and weakness in the lower esophageal sphincter muscle causing severe acid reflux. In such cases, we recommend a hiatal hernia repair with gastric bypass surgery.
Is Lap Band conversion to gastric sleeve a good option for me?
Many factors are taken into consideration when deciding whether or not you are a good candidate for Lap Band conversion to gastric sleeve. After thorough assessment and physical examination, Dr. Darido will discuss the various treatment options that will be of benefit to you. Around 60% of our patients qualify for gastric sleeve surgery after Lap Band removal.
Who should do your revision surgery?
It is extremely important to choose a knowledgeable bariatric and acid reflux surgeon with expertise in advanced laparoscopic foregut surgery to perform your Lap band revision. Why? Lap Band affects esophageal function and motility. Lap band causes the development of esophageal diverticula and hiatal hernias. Lap Band conversion to sleeve or gastric bypass surgery must address all these issues to achieve the best possible outcome.
How much does weight loss surgery revision cost?
Surgery cost varies depending on your insurance plan. Our insurance and finance specialists are available to answer all your financial questions.
What is my recovery time?
You will usually spend a night or two in the hospital after surgery. It takes around 10 days before you can go back to work.
Lets get started
If you currently have a Lap Band, we encourage you to contact our office for a private consultation. Dr. Darido will offer you a thorough evaluation and you and Dr. Darido will formulate a safe and effective treatment plan.
Request Consultation
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#### Lap Band Surgery
Adjustable Gastric Band Surgery
Overview:
Adjustable gastric band surgery also known as Lap Band is a weight loss procedure that has failed to provide durable weight loss. It was initially developed as a less invasive alternative to gastric bypass.
How is Lap Band surgery performed?
Adjustable gastric band surgery is performed laparoscopically (through tiny incisions). An inflatable silicon band is placed around the upper stomach creating a small pouch. The assumption was that a small gastric pouch will force a patient to eat less and hence loose weight.
How does adjustable gastric band surgery work?
Here is the problem. Gastric banding doesn’t work in the majority of patients. Unlike Roux-en-Y gastric bypass and sleeve gastrectomy, lap band surgery is not associated with hormonal changes that promote satiety and boost metabolism. Lap band surgery is purely restrictive resulting in poor long-term weight loss. For this reason, Dr. Darido does not recommend adjustable gastric banding to any of his patients.
Are you over-restricted?
Many gastric band patients suffer from band over-restriction due to aggressive band filling. Over-restriction does not result in durable weight loss. On the contrary, band over-restriction leads to many serious complications. If you have a gastric band and suffer from vomiting, heartburn, food regurgitation, difficulty swallowing, or nighttime cough, you may be over-restricted.
Lets get started
Dr. Darido has an extensive experience dealing with lap band revision surgery. If you have a gastric band and you are not happy with your weight loss results, we would love to help you. Please contact our office for a private one on one consultation.
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#### Manga gástrica en Houston
Visión general:
La cirugía de manga gástrica es actualmente el procedimiento de pérdida de peso más comúnmente realizado en Houston. La cirugía de manga gástrica ha ganado gran popularidad en los últimos años debido a su eficacia y simplicidad.

¿Cómo se realiza la cirugía de manga gástrica?
La cirugía de manga gástrica se realiza por vía laparoscópica (a través de pequeñas incisiones). La cirugía consiste en transectar el 85% del estómago. Los intestinos no se redirigen (como la cirugía de derivación o bypass gástrico). Como resultado, no hay riesgo de hernia interna o formación de úlceras marginales. Esto hace que la manga esté casi libre de riesgos a largo plazo. La falta de efectos secundarios a largo plazo es una ventaja importante para la gastrectomía en manga en comparación con el bypass gástrico y la cirugía de cruce duodenal.
¿Cómo funciona la manga?
La cirugía de manga gástrica es un procedimiento restrictivo y metabólico. El volumen de la manga gástrica es muy pequeño, por lo tanto, el tamaño de su comida no es más de la mitad a una taza llena. Sin embargo, la restricción por sí sola no es suficiente para perder peso. La cirugía de manga frena su hambre, disminuye los antojos de alimentos y aumenta su metabolismo. Esto es secundario a cambios hormonales como la ghrelina, también conocida como la hormona del hambre.
¿La cirugía de manga gástrica es una buena opción para mí?
Muchos factores se toman en consideración al decidir si usted es o no un buen candidato para la cirugía de manga gástrica. Después de una evaluación exhaustiva y un examen físico, el Dr. Darido discutirá las diversas opciones de tratamiento que serán de beneficio para usted. Alrededor del 70% de nuestros pacientes califican para la cirugía de manga gástrica.
¿Quién debe realizar su manga gástrica en Houston?
Es extremadamente importante elegir un cirujano experto en bariátrico y de reflujo ácido para realizar su gastrectomía en manga. ¿Por qué? La resección gástrica incompleta resulta en una pérdida de peso inadecuada. El aspecto más importante de la cirugía de manga gástrica es la resección de la parte del estómago que se hincha, también llamada fondo gástrico. El fondo gástrico es la parte del estómago que se estira para acomodar una comida ingerida. El fondo gástrico también secreta la hormona del hambre llamada ghrelina. La resección incompleta del fondo gástrico no dará lugar a la restricción y el cambio hormonal necesarios para lograr una pérdida de peso adecuada. Además, la mayoría de los pacientes con sobrepeso tienen reflujo ácido debido a la hernia hiatal. La hernia hiatal ocurre cuando la parte superior del estómago o el fondo gástrico se mueve hacia el pecho desde su ubicación abdominal normal. La reparación de la hernia hiatal debe realizarse al mismo tiempo que la gastrectomía en manga para prevenir el reflujo ácido severo después de la cirugía de pérdida de peso.
¿Cuánto cuesta la cirugía de manga gástrica de Houston?
El costo de la cirugía varía según su plan de seguro. Nuestros especialistas en seguros y finanzas están disponibles para responder a todas sus preguntas financieras.
¿Cuál es mi tiempo de recuperación?
Por lo general, pasará una o dos noches en el hospital después de la cirugía. Se tarda alrededor de 10 días antes de que pueda volver al trabajo.
Comencemos
Si desea obtener más información sobre la cirugía de manga, le recomendamos que se comunique con nuestra oficina para una consulta privada. Durante esta sesión relajada e informativa, conocerá al Dr. Darido y aprenderá si la cirugía de manga gástrica puede funcionar para usted.

#### Meet Dr. Elias Darido
Dr. Elias Darido, founder of Houston Weight Loss Surgery Center
In today’s healthcare environment, many overweight patients are falling victims to fad diets, fake pills and false promises. Obesity is a complex medical disease that has reached an epidemic level in Houston. Caring for overweight patients requires experience, knowledge, research, and dedication. Obesity treatment is neither a simple pill you take every day nor a certain diet you adopt for a couple of weeks. Obesity treatment is a life journey. At Houston Weight Loss Surgery Center, Dr. Darido is very proud and privileged to be part of your weight loss journey.
Dr. Darido specialized in advanced minimally invasive and weight loss surgery at the University of North Carolina in Chapel Hill. His expertise encompasses several surgeries including sleeve gastrectomy, gastric bypass and hiatal hernia repair. He is considered an expert in managing acid reflux disease in overweight patients.
Throughout his career, Dr. Darido has developed several innovative new procedures for treatment of gastroparesis, obesity and diabetes. Gastric Fundus Invagination or Sleeve Gastrotomy is a novel weight loss procedure that Dr. Darido is currently studying to promote gastric emptying. The surgery is reversible and simple to perform allowing patients to recover fast and with minimal pain. Gastric Fundus Invagination mimics the effects of a traditional sleeve gastrectomy without the need to cut the stomach.
Dr. Darido aspires to provide effective, simple and safe weight loss solutions for patients in Houston and the surrounding areas. If you are 80 or more pounds over your ideal weight, have failed to lose or maintain weight loss through more conservative approaches, and wish to consider a surgical alternative, you will greatly benefit from Dr. Darido’s expertise.
Dr. Darido holds the following designations:

Fellow of the American College of Surgeons
Board Certified The American Board of Surgery
Member American Society of Metabolic and Bariatric Surgery (ASMBS)
Member Society of American Gastrointestinal Endoscopic Surgeons (SAGES)
Member American College of Surgeons (ACS)
Member Texas Medical Association (TMA)
Member Harris County Medical Association (HCMA)
Member Houston society of Bariatric Surgeons
Fellowship Trained in Advanced Laparoscopy Surgery
Fellowship Trained in Metabolic and Bariatric Surgery

“Effective, safe and durable weight loss treatment solutions“ is the vision of Dr. Elias Darido.
Association Memberships

#### Notice of Privacy Practices
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Houston Sleeve Surgeon (Houstonsleevesurgeon.com) uses and discloses health information about you for treatment, to obtain payment for treatment, for administrative purposes, and to evaluate the quality of care that you receive. This notice describes our privacy practices. You can request a copy of this notice at any time.
Treatment, Payment, Health Care Operations
Treatment
We are permitted to use and disclose your medical information to those involved in your treatment. For example your care may require the involvement of another doctor. When we refer you to another doctor, we will share some or all of your medical information with that physician to facilitate the delivery of care. Since the physician in this practice is a specialist, when we provide treatment, we may request that your primary care physician receive or provide information
about your particular condition so that he or she can appropriately treat you for other medical conditions, if any.
Payment
We are permitted to use and disclose your medical information to bill and collect payment for services provide to you. For example, we may complete a claim form to obtain payment from your insurer or HMO. The form will contain medical information, such as a description of the medical service provided to you, that your insurer or HMO needs to approve payment to us.
Health Care Operations
We are permitted to use or disclose your medical information for the purposes of health care operations, which are activities that support this practice and ensure that quality care is delivered. For example, we may engage the services of a professional to aid this practice in its compliance programs; this person will review billing and medical files to ensure we maintain our compliance with regulations and the law. Or we may ask another physician to review this practice’s charts and medical records to evaluate our performance so that we may ensure that only the best health care is provided by this practice.
Disclosures That Can Be Made Without Your Authorization
There are situations in which we are permitted by law to disclose or use your medical information without your written authorization or an opportunity to object. In other situations we will ask for your written authorization before using or disclosing any identifiable health information about you. If you choose to sign an authorization to disclose information, you can later revoke that authorization, in writing, to stop future uses and disclosures. However, any revocation will not apply to disclosures or uses already made or taken in reliance on that authorization.
Public Health, Abuse or Neglect, and Health Oversight
We may disclose your medical information for public health activities. Public health activities are mandated by federal, state, or local government for the collection of information about disease, vital statistics (like births and death), or injury by a public health authority. We may disclose medical information, if authorized by law, to a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition. We may disclose
your medical information to report reactions to medications, problems with products, or to notify people of recalls or products they may be using.

We may also disclose medical information to a health oversight agency authorized to receive reports of child abuse or neglect. Texas law requires physicians to report child abuse or neglect. Regulations also permit the disclosure of information to report abuse or neglect of elders or the disabled.

We may disclose your medical information to a health oversight agency for those activities authorized by law. Examples of these activities are audits, investigations, licensure applications and inspections which are all government activities undertaken to monitor the health care delivery system and compliance with other laws, such as civil rights laws.
Legal Proceedings and Law Enforcement
We may disclose your medical information in the course of judicial or administrative proceedings in response to an order of the court (or the administrative decision-maker) or other appropriate legal process. Certain requirements must be met before the information is disclosed.

If asked by a law enforcement official, we may disclose your medical information under limited circumstances provided that the information:

 	Is released pursuant to legal process, such as a warrant or subpoena;
 	Pertains to victim of crime and your are incapacitated;
 	Pertains to a person who has died under circumstances that may be related to criminal conduct;
 	Is about a victim of crime and we are unable to obtain the person’s agreement;
 	Is released because of a crime that has occurred on these premises; or
 	Is released to locate a fugitive, missing person, or suspect.
 	We may also release information if we believe the disclosure is necessary to prevent or lessen an imminent threat to
the health or safety of a person.

Workers’ Compensation
We may disclose your medical information as required by the Texas workers’ compensation law.
Inmates
If you are an inmate or under the custody of law enforcement, we may release your medical information to the correctional institution or law enforcement official. This release is permitted to allow the institution to provide you with medical care, to protect tour health or the health and safety of others, or for the safety and security of the institution.
Military, National Security and Intelligence Activities, Protection of the President
We may disclose your medical information for specialized governmental functions such as separation or discharge from military service, requests as necessary by appropriate military command officials (if you are in the military), authorized national security and intelligence activities, as well as authorized activities for the provision of protective services fro the President of United States, other authorized government officials, or foreign heads of state.
Research, Organ Donation, Coroners, Medical Examiners, and Funeral Directors
When a research project and its privacy protections have been approved by an Institutional Review Board or privacy board, we, may release medical information to researchers for research purposes. We may release medical information to organ procurement organizations for the purpose of facilitating organ, eye, or tissue donation if you are a donor.

Also, we may release your medical information to a coroner or medical examiner to identify a deceased or cause of death. Further, we may release your medical information to a funeral director where such a disclosure is necessary for the director to carry out his duties.
Required by Law
We may release your medical information where the disclosure is required by law.
Your Rights Under Federal Privacy Regulations
The United States Department of Health and Human Services created regulations intended to protect patient privacy as required by the Health Insurance Portability and Accountability Act (HIPAA). Those regulations create several privileges that patients may exercise. We will not retaliate against a patient
that exercises their HIPAA rights.
Requested Restrictions
You may request that we restrict or limit how your protected health information is used or disclosed for treatment, payment, or healthcare operations. We do NOT have to agree to this restriction, but if we do agree, we will comply with your request except under emergency circumstances.

To request a restriction, submit the following in writing: (a) The information to be restricted, (b) what kind of restriction you are requesting (i.e. on the use of information, disclosure of information or both), and (c) to whom the limits apply. Please send the request to the address and person listed below. You may also request that we limit disclosure to family members, other relatives, or close personal friends that may or may not be involved in your care.
Receiving Confidential Communications by Alternative Means
You may request that we send communications of protected health information by alternative means or to an alternative location. This request must be made in writing to the person listed below. We are required to accommodate only reasonable requests. Please specify in your send it to a particular place, the contact/address information.
Inspection and Copies of Protected Health Information
You may inspect and/or copy health information that is within the designated record set, which is information that is used to make decisions about your care. Texas law requires that requests for copies be made in writing and we ask that requests for inspection of your health information also be made in writing. Please send your request to the person listed below.

We can refuse to provide some of the information you ask to inspect or ask to be coped if the information:

 	Includes psychotherapy notes.
 	Includes the identity of a person who provided information if it was obtained under a promise of
confidentiality,
 	Is subject to the Clinical Laboratory Improvements Amendments of 1988.
 	Has been compiled in anticipation of litigation.

We can refuse to provide access to or copies of some information for other reasons, provided that we provide a review of our decision on your request. Another licensed health care provider who was not involved in a prior decision to deny access will make any such review.

Texas law requires that we are ready to provide copies or a narrative within 15 days of your request. We will inform you of when the records are ready or if we believe access should be limited. If we deny access, we will inform you in writing.

HIPPA permits us to charge a reasonable cost based fee. The Texas State Board of Medical Examiners (TSBME) has set limits on fees for copies of medical records that under some circumstances may be lower than the charges permitted by HIPAA. In any event, the lower of the fee permitted by HIPAA or
the fee permitted by the TSBME will be charged.

Amendment of Medical Information

You may request an amendment of your medical information in the designated record set. Any such request must be made in writing to the person listed below. We will respond within 60 days of your request. We may refuse to allow an amendment if the information:

 	Wasn’t created by this practice or the physicians here in this practice.
 	Is not part of the Designated Record Set
 	Is not available for inspection because of an appropriate denial.
 	If the information is accurate and complete.

Even if we refuse to allow an amendment you are permitted to include a patient statement about the information at issue in your medical record. If we refuse to allow an amendment, we will inform you in writing. If we approve the amendment, we will inform you in writing, allow the amendment to be made and tell others that we know have the incorrect information.
Accounting of Certain Disclosures
The HIPPA privacy regulations permit you to request, and us to provide, an accounting of disclosures that are other than for treatment, payment, health care operations, or made via an authorization signed by you or your representative. Please submit any request for an accounting to the person listed below.
Your first accounting of disclosures (within a 12 month period) will be free. For additional requests within that period we are permitted to charge for the cost of providing the list. If there is a charge we will notify you and you may choose to withdraw or modify your request before any costs are incurred.
Appointment reminders, Treatment Alternatives, and Other Health-related Benefits
We may contact you by telephone, mail, or email to provide appointment reminders, information about treatment alternatives, or other health-related benefits and services that may be of interest to you.
Complaints
If you are concerned that your privacy rights have been violated, you may contact the person listed below. You may also send a written complaint to the United States Department of Health and Human Services. We will not retaliate against you for filing a complaint with the government or us. The contact information for the United States Department of Health and Human Services is:

U.S. Department of Health and Human Services HIPAA Complaint 7500 Security Blvd., C5-24-04, Baltimore, MD 21244
Our Promise to You
We are required by law and regulation to protect the privacy of your medical information, to provide you with this notice of our privacy practices with respect to protect health information, and to abide by the terms of the notice of privacy practices in effect.

#### Patient Forms
Informed Consent Endoscopy
Informed Consent Manometry

#### Patient Reviews
Video Testimonials

Patient Reviews*
Dr. Darido and his team are grateful for our patient’s weight loss reviews. If you are a patient, please use this form to submit your review.
* Individual results may vary. All before and after photos, testimonials and opinions on this website are the results of the individual represented. Your weight loss results may vary in terms of length of time and/or amount of weight loss. Although weight loss represented may be typical for the type of weight loss surgery, there is no guarantee of your individual results.
Jimmy S.
Dr. Darido, spent more time with my wife and I than any other doctor, in our combined lives. He was very knowledgable about his craft and he made certain we understood the process of what to expect before and after surgery. Additionally, he was there every step of the way, from the first contrasting imaging session, through the selection of procedures, before surgery and he ensured that all was well after surgery and both he and his staff followed up regularly to check in.
In this fast paced society where you are treated like a number, or a patient by so many… Dr. Darido, treats you like a friend… He gave us his personal cell phone to call should we have any questions before the procedure and in the weeks following the procedure.
Dr. Darido is the “BEST” of them all!
Feb 26, 2016
* Individual results may vary

Crystal P.

Excellent doctor that truly cares about his patients and is extremely knowledgeable. Dr. Darido went above and beyond to make sure my surgery went smoothly and safely. I am very pleased with the care I have received and will recommend Dr. Darido to anyone interested in weight loss surgery. He deserves ten stars!!!!
Jan 03, 2016
* Individual results may vary

Amanda U.

Dr. Darido is very professional and candid about the process. He is excellent with patient care and quality of life. He is vey personable and compassionate about his work. I would fecommend Dr.Darido and his staff.
Oct 21, 2015
* Individual results may vary

Sharon E.

Dr. Darido is an amazing doctors, he is caring and he listens to his patient he’s never in a rush when I come for my appointment. The fist time I seen him my blood pressure was really high and he was very concerned he didn’t was me to leave his office he got on the phone with another colleague and asked her to see me right away she did and I was able to get my BP under control. I had my surgery 8/25/15 and I feel amazing I have lost 40 pounds. I have not take any BP medication since my surgery. Thank you Dr Darido for helping me get my health back on track. If you are looking for a good caring doctor please contact My doctor.
Oct 08, 2015
* Individual results may vary

Tammy M.

I couldn’t be more pleased with my experience with Dr. Darido and his staff. Dr. Darido always had the time to answer any question and explain every aspect of my surgery. The results of my surgery have been overwhelming and I highly recommend him.
Aug 21, 2015
* Individual results may vary

Lisa L.

He is a great doctor. He is thorough and detailed and very patient . He describes in detail the diagnosis and the procedure required. I would recommend him highly to anyone.
Jun 10, 2015
* Individual results may vary

Terry M.

The sleeve is still the best decision I have ever made in my life. I have been so much more active than ever. I play Tennis, i go on cruises and I am able to enjoy every second of my life. You did an amazing job Dr. Darido and will forever be thankful to you.
Jun 09, 2015
* Individual results may vary

Juan G.

Dr. Darido is a great listener, and makes me feel like a special person, not a number. I was very comfortable with his recommendations, and I started feeling better after talking to him. I highly recommend Dr. Darido.
May 15, 2015
* Individual results may vary

Steverson M.

Dr. Darido perform my gastric sleeve surgery and made me feel extremely comfortable and confident throughout the entire process. he was extremely thorough and I really appreciate is understanding and down to earth demeanor.
May 15, 2015
* Individual results may vary

Nicole S.

I cannot thank Dr. Darido enough for what he has done to my husband and me. Our life has completely changed after surgery. My husband had surgery first and 3 months later I was next. I have suffered with high blood sugar for years and now I am insulin free. No more injections!! My back and knees don’t hurt anymore. I play with my grandkids and I can walk my dog for hours. Having the gastric bypass was the best decision of my life and I would recommend it to anyone taking insulin injections for Diabetes.
May 11, 2015
* Individual results may vary

Davis T.

Dr Darido has a great bedside manner. He took the time to explain all aspects of lap band removal and conversion to gastric bypass. It was a great experience for me and I highly recommend Dr D
May 10, 2015
* Individual results may vary

Dina A.

Dr. Darido is Amazing!!!! It was so worth going to him and getting the gastric bypass.
I had been struggling with weight since I was little and got worse after puberty hit. I was depressed and very isolated because of my weight. But after the surgery everything is changed , i get my self confidence back ! it was the best option for me . Thank you Dr Elias !
May 10, 2015
* Individual results may vary

#### Privacy Policy
Introduction
This website is operated by Elias F Darido, MD PLLC (collectively the “Company”, “We” or “Us”) respect your privacy and the Company is committed to protecting it through our compliance with this policy.
This policy describes the types of information we may collect from you or that you may provide when you visit this website (our “Website”) and our practices for collecting, using, maintaining, protecting and disclosing that information.
This policy applies to information we collect:

On this Website
In email, text, phone and other electronic messages between you and this Website.
Through mobile and desktop applications you download from this Website, which provide dedicated non-browser-based interaction between you and this Website.

It does not apply to information collected by:

Us offline or through any other means, including on any other website operated by Company or any third party (including our affiliates and subsidiaries) that may link to or be accessible from or on the Website. Note that patient health information will be governed by a separate HIPAA Notice of Privacy Practices provided by your healthcare provider at the time of services.

Please read this policy carefully to understand our policies and practices regarding your information and how we will treat it. This policy is incorporated into our Terms of Use and creates a contract between the Company and you. If you do not agree with our policies and practices, your sole choice is not to use our Website. By accessing or using this Website, you agree to this privacy policy and the Terms. This policy may change from time to time. All changes are effective immediately when we post them, and apply to all access to and use of the Website thereafter. Your continued use of this Website after we make changes is deemed to be acceptance of those changes, so please check the policy periodically for updates.
Children Under the Age of 16
Our Website is not intended for children under 16 years of age. No one under age 16 may provide any personal information to or on the Website. We do not knowingly collect personal information from children under 16. If you are under 16, do not use or provide any information on this Website or on or through any of its features/register on the Website, make any purchases through the Website, use any of the interactive or public comment features of this Website or provide any information about yourself to us, including your name, address, telephone number, email address or any screen name or username you may use. If you are aware that we have inadvertently collected personal information from a child under the age of 16, please write to us using the information on our contact page to request deletion of that information.
Information We Collect About You and How We Collect It
We collect several types of Personal Information from and about users of our Website, including information:

By which you may be personally identified, such as name, postal address, email address, and telephone number.
Consumer information, like your preferences or a consumer profile based on your use of the website.
Insurance information.
General health information, like your gender, height, weight or generalized medical conditions that you may be seeking information about.
Social media information, such as social media handles, content and other data shared with us through third-party features that you use on our Site and other services (such as apps, tools, payment services, widgets and plug-ins offered by social media services, like Facebook, Instagram and LinkedIn, that may have referred you to our Site).
Information about your device, your internet connection, the equipment you use to access our Website, and usage details.

We collect this information:

Directly from you when you provide it to us.
Automatically as you navigate through the site. Information collected automatically may include usage details, IP addresses and information collected through cookies, pixels, web beacons and other tracking technologies.

Information You Provide to Us
The information we collect on or through our Website may include:

Information that you provide by filling in forms on our Website. This includes information provided at the time of registering to use our Website, subscribing to our service, posting material, or requesting further services. We may also ask you for information when you enter a contest or promotion sponsored by us, and when you report a problem with our Website.
Records and copies of your correspondence (including email addresses), if you contact us.
Your responses to surveys that we might ask you to complete for research purposes.
Details of transactions you carry out through our Website and of the fulfillment of your orders. You may be required to provide financial and personal information before placing an order through our Website.
Your search queries on the Website.

Mobile Numbers and Text Messaging
The user agrees any mobile phone number(s) provided by them to Elias F Darido, MD PLLC shall be unique to that user. The user agrees mobile number(s) provided are not shared with, or common to, other users. If a user changes their mobile phone number(s), it is the user’s responsibility to contact us to update their mobile phone number in a timely manner.

Message/data rates may apply per phone plan.
Message frequency varies.
Some carriers may not be supported.
Reply STOP to end messages.

Information We Collect Through Automatic Data Collection Technologies
As you navigate through and interact with our Website, we may use automatic data collection technologies to collect certain information about your equipment, browsing actions and patterns, including:

Details of your visits to our Website, including traffic data, location data, logs and other communication data and the resources that you access and use on the Website.
Information about your computer and internet connection, including your IP address, operating system and browser type.

The information we collect automatically may include personal information, or we may maintain it or associate it with personal information we collect in other ways or receive from third parties. It helps us to improve our Website and to deliver a better and more personalized service, including by enabling us to:

Estimate our audience size and usage patterns.
Store information about your preferences, allowing us to customize our Website according to your individual interests.
Speed up your searches.
Recognize you when you return to our Website.

The technologies we use for this automatic data collection may include:

Cookies (or browser cookies). A cookie is a small file placed on the hard drive of your computer. You may refuse to accept browser cookies by activating the appropriate setting on your browser. However, if you select this setting you may be unable to access certain parts of our Website. Unless you have adjusted your browser setting so that it will refuse cookies, our system will issue cookies when you direct your browser to our Website.
Flash Cookies. Certain features of our Website may use flash cookies to collect and store information about your preferences and navigation to, from and on our Website. Flash cookies are not managed by the same browser settings as are used for browser cookies.
Web Beacons. Pages of our Website and our emails may contain small electronic files known as web beacons (also referred to as clear gifs. pixel tags and single-pixel gifs) that permit the Company, for example, to count users who have visited those pages or opened an email and for other related website statistics (for example, recording the popularity of certain website content and verifying system and server integrity).
Javascript which uses third-party services to store data about activities and transactions.
Trackable telephone numbers which keep track of phone calls made to some phone numbers on this site.
Offline website data – including both local and remote storage of activities.
Geo-targeting information about your general location at the time of use of the site.

We may tie this information to personal information about you that we collect from other sources or you provide to us.
By using the Site, you consent to our use of these Tracking Technologies. You can decide if and how your computer will accept a cookie by configuring your preferences or options in your browser. However, if you choose to reject cookies, you may not be able to use certain online products, services or features on the Website. For example, we may not be able to recognize your computer or device, and you may need to log in every time you visit. You can get more information about Cookies and Tracking Technologies, and instructions on how to opt out of these items, you may visit All About Cookies. You may also learn more at the Digital Advertising Alliance or the NAI industry opt-out platform.
How We Use Your Information
We use information that we collect about you or that you provide to us, including any personal information:

To present our Website and its contents to you.
To provide you with information, products or services that you request from us.
To fulfill any other purpose for which you provide it.
To provide you with notices about your account/subscription, including expiration and renewal notices.
To carry out our obligations and enforce our rights arising from any contracts entered into between you and us, including for billing and collection.
To notify you about changes to our Website or any products or services we offer or provide through it.
To allow you to participate in interactive features on our Website.
In any other way we may describe when you provide the information.
For any other purpose with your consent.

Your Access to and Control Over Information
You may opt out of any future contacts from us at any time. You can do the following at any time by contacting us via the email address or phone number given on our website. The jurisdiction in which you reside may dictate the rights available to you, but they may include the right to:

See what data we have about you, if any.
Change/correct any data we have about you.
Opt-out of our sharing of certain information.
Have us delete any data we have about you.
Express any concern you have about our use of your data.

If applicable, you may exercise any of your rights by submitting a verifiable data subject request to us by using the information in the “Contact Us” section below. You may make a request related to your Personal Information or on behalf of someone for which you have authorization. You must include your full name and email address in your request. We may require you to confirm your identity and/or legal standing for the request as well as your residency to obtain the information.
Please note that we will ask you to verify your identity before responding to such requests, and we may deny your request if we are unable to verify your identity or authority to make the request.
Disclosure of Your Information
We may disclose aggregated information about our users, and information that does not identify any individual, for any reason without restriction.
We may disclose personal information that we collect or you provide as described in this privacy policy:

To fulfill the purpose for which you provide it.
To allow our service providers to complete a service we have contracted with them to provide.
For any other purpose disclosed by us when you provide the information.
With your consent.
To any potential acquirer, successor or assignee as part of any business transaction for the merger, sale, transfer, assignment or reorganization of our business or assets.
To comply with any court order, law or legal process, including to respond to any government or regulatory request.

Privacy of Collected Data
We will never use the statistical analytics tool to track or to collect any names or email addresses of visitors to our site. Google will not associate your IP address or device ID with any other data held by Google. Neither we nor Google will link, or seek to link, an IP address or a device ID with the identity of a computer user.
Information About Remarketing
We specifically share your information with Google (including YouTube, Google Analytics, Google AdSense, Google Business Profiles) and Meta (including Facebook and Instagram). We use Google Analytics to help us understand how our customers use the Site. Read more about how Google uses your Personal Information or opt-out of Google Analytics. You have the option to manage Google’s personalized ads by visiting the Google advertising center. You can read more about how Meta uses your Personal Information and how to manage your Meta ad preferences. You can read Vimeo’s privacy policy and information on Vimeo’s video privacy settings. Please note that depending on your settings, the next time you access our Services the analytics may be reactivated, so you may have to disable the technology each time.
This website uses Google remarketing to advertise online using text or image ads on the Google Display Network. Remarketing is a feature that lets us reach people who have previously visited our site, and show them relevant ads when they visit other sites on the Google Display Network.
For websites using remarketing, a third-party DoubleClick cookie is used to enable remarketing for products like AdWords on the Google Display Network. When someone visits our website, a few lines of code will drop an anonymous browser cookie. This cookie is a small file that stores information. The cookie will store the site visit, but does not store any sensitive information, such as visitor name, address or any other piece of information that might personally identify the visitor. The cookie will be enabled for a set period of time, such as 30 or 60 days, at which time, the cookie expires.
What is the Google Display Network?
A group of more than a million websites, videos, and apps where ads can appear. Sites in this network have partnered with Google to show relevant ads.
Opting out of Remarketing
Visitors may opt out of Google’s use of cookies by visiting the Ads Preferences Manager.
Visitors may opt out of a third-party vendor’s use of cookies by visiting the Network Advertising Initiative opt-out page.
Do Not Track Signals
Our Site currently does not respond to Do Not Track (“DNT”) signals and operates as described in this Policy, whether or not a DNT signal is received.
Global Privacy Control
Some browsers and browser extensions support the Global Privacy Control (“GPC”) that can send a signal to the websites you visit indicating your choice to opt-out from certain types of data processing, including data sales. GPC is a web-browser level setting, maintained by either a browser or a browser extension, that is typically set by the user, not the website. In certain regions, when we detect such a signal, we will make reasonable efforts to respect your choices indicated by a GPC setting as required by applicable law.
Changes to Our Privacy Policy
Our Privacy Policy may change from time to time and all updates will be posted on this page. If you feel that we are not abiding by this privacy policy, you should contact us immediately via the email address or phone number given on our website.
Contact Information
If there are any questions regarding this privacy policy you may contact us using the information below.
Houston Sleeve Surgeon
2100 W. Loop South, Suite 1115B
Houston, TX 77027
832-963-1803

#### Terms of Use
Introduction
This website is operated by Elias F Darido, MD PLLC (collectively the “Company”, “We” or “Us”). The use of our website is subject to the following terms and conditions of use, as amended from time to time (the “Terms”). The Terms are to be read together by you with any terms, conditions or disclaimers provided in the pages of our website. Please review the Terms carefully. They constitute a legal contract between you and the Company. The Terms apply to all users of our website, including without limitation, users who are browsers, customers, merchants, vendors and/or contributors of content. If you access and use this website, you accept and agree to be bound by and comply with the Terms and our Privacy Policy. If you do not agree to the Terms or our Privacy Policy, you are not authorized to access our website, use any of our website’s services or place an order on our website.
Use of Our Website
The information on this Site is for information or educational purposes only. It is not intended to provide medical advice or diagnose any condition. You agree to use our website for legitimate purposes and not for any illegal or unauthorized purpose, including without limitation, in violation of any intellectual property or privacy law. By agreeing to the Terms, you represent and warrant that you are at least the age of majority in your state or province of residence and are legally capable of entering into a binding contract.
You agree to not use our website to conduct any activity that would constitute a civil or criminal offense or violate any law. You agree not to attempt to interfere with our website’s network or security features or to gain unauthorized access to our systems.
You agree to provide us with accurate personal information, such as your email address, mailing address and other contact details in order to complete your order or contact you as needed. You authorize us to collect and use this information to contact you in accordance with our Privacy Policy.
General Conditions
We reserve the right to refuse service to anyone, at any time, for any reason. We reserve the right to make any modifications to the website, including terminating, changing, suspending or discontinuing any aspect of the website at any time, without notice. We may impose additional rules or limits on the use of our website. You agree to review the Terms regularly and your continued access or use of our website will mean that you agree to any changes.
You agree that we will not be liable to you or any third party for any modification, suspension or discontinuance of our website or for any service, content, feature or product offered through our website.
Consent to Electronic Communications
You agree that we may communicate with you electronically regarding your use of the website or the services and that any notices, agreements, disclosures or other communications that we send to you electronically will satisfy any legal communication requirements including any requirement that the communications be in writing. To withdraw your consent to receiving electronic notices, please notify us at the information on the Contact page of our website.
SMS Terms and Conditions
By providing your mobile phone number and opting in to receive text messages from Elias F Darido, MD PLLC, you consent to receive SMS communications related to appointment reminders, scheduling confirmations, post-procedure instructions, billing notifications, practice updates, and promotional or marketing messages such as special offers, new services, and announcements.

Message frequency varies and message and data rates may apply.
You may opt out of receiving text messages at any time by replying STOP to any message.
Consent to receive SMS messages is not a condition of purchase or service.
Carriers are not liable for delayed or undelivered messages.

Products or Services
All purchases through our website are subject to product availability. We may, in our sole discretion, limit or cancel the quantities offered on our website or limit the sales of our products or services to any person, household, geographic region or jurisdiction.
Prices for our products are subject to change, without notice. Unless otherwise indicated, prices displayed on our website are quoted in U.S. dollars.
We reserve the right, in our sole discretion, to refuse orders, including without limitation, orders that appear to be placed by distributors or resellers. If we believe that you have made a false or fraudulent order, we will be entitled to cancel the order and inform the relevant authorities.
We do not guarantee the accuracy of the color or design of the products on our website. We have made efforts to ensure the color and design of our products are displayed as accurately as possible on our website.
Links to Third-Party Websites
Links from or to websites outside our website are meant for convenience only. We do not review, endorse, approve or control, and are not responsible for any sites linked from or to our website, the content of those sites, the third parties named therein, or their products and services. Linking to any other site is at your sole risk and we will not be responsible or liable for any damages in connection with linking. Links to downloadable software sites are for convenience only and we are not responsible or liable for any difficulties or consequences associated with downloading the software. Use of any downloaded software is governed by the terms of the license agreement, if any, which accompanies or is provided with the software.
Patient Portal Account Creation
To access and use the Patient Portal, we may require you to first register for an Account. You must provide accurate, current and complete information during the registration process and you must keep your information updated. You are responsible for maintaining the confidentiality of your account and password and for restricting access to your computer or device, and you agree to accept responsibility for all activities that occur under your registration, username, password and/or patient account. We may, in our sole discretion, terminate your account or use of the portal at any time and for any or no reason.
Use Comments, Feedback, and Other Submissions
You acknowledge that you are responsible for the information, profiles, opinions, messages, comments and any other content (collectively, the “Content”) that you post, distribute or share on or through our website or services available in connection with our website, including our social media sites. You further acknowledge that you have full responsibility for the Content, including but limited to, with respect to its legality, and its trademark, copyright and other intellectual property ownership.We do not wish to receive any confidential, proprietary or sensitive information from you via the website or your comments.
You agree that any content submitted by you in response to a request by us for a specific submission may be edited, adapted, modified, recreated, published, or distributed by us. You further agree that we are under no obligation to maintain any Content in confidence, to pay compensation for any Content or to respond to any Content.
You agree that you will not post, distribute or share any Content on our website that is protected by copyright, trademark, patent or any other proprietary right without the express consent of the owner of such proprietary right. You further agree that your Content will not be unlawful, abusive or obscene nor will it contain any malware or computer virus that could affect our website’s operations. You will be solely liable for any Content that you make and its accuracy. We have no responsibility and assume no liability for any Content posted by you or any third-party.
We reserve the right to terminate your ability to post on our website and to remove and/or delete any Content that we deem objectionable. You consent to such removal and/or deletion and waive any claim against us for the removal and/or deletion of your Content.
Your Personal Information
Please see our Privacy Policy to learn about how we collect, use, and share your personal information.
Errors and Omissions
Please note that our website may contain typographical errors or inaccuracies and may not be complete or current. We reserve the right to correct any errors, inaccuracies or omissions and to change or update information at any time, without prior notice (including after an order has been submitted). Such errors, inaccuracies or omissions may relate to product description, pricing, promotion and availability and we reserve the right to cancel or refuse any order placed based on incorrect pricing or availability information, to the extent permitted by applicable law. We do not undertake to update, modify or clarify information on our website, except as required by law.
Disclaimer and Limitation of Liability
You assume all responsibility and risk with respect to your use of our website, which is provided “as is” without warranties, representations or conditions of any kind, either express or implied, with regard to information accessed from or via our website, including without limitation, all content and materials, and functions and services provided on our website, all of which are provided without warranty of any kind, including but not limited to warranties concerning the availability, accuracy, completeness or usefulness of content or information, uninterrupted access, and any warranties of title, non-infringement, merchantability or fitness for a particular purpose. We do not warrant that our website or its functioning or the content and material of the services made available thereby will be timely, secure, uninterrupted or error-free, that defects will be corrected, or that our websites or the servers that make our website available are free of viruses or other harmful components.
The use of our website is at your sole risk and you assume full responsibility for any costs associated with your use of our website. We will not be liable for any damages of any kind related to the use of our website.
In no event will we, or our affiliates, our or their respective content or service providers, or any of our or their respective directors, officers, agents, contractors, suppliers or employees be liable to you for any direct, indirect, special, incidental, consequential, exemplary or punitive damages, losses or causes of action, or lost revenue, lost profits, lost business or sales, or any other type of damage, whether based in contract or tort (including negligence), strict liability or otherwise, arising from your use of, or the inability to use, or the performance of, our website or the content or material or functionality through our website, even if we are advised of the possibility of such damages.
Certain jurisdictions do not allow limitation of liability or the exclusion or limitation of certain damages. In such jurisdictions, some or all of the above disclaimers, exclusions, or limitations, may not apply to you and our liability will be limited to the maximum extent permitted by law.
Indemnification
You agree to hold us and our affiliates, including any party involved in creating, producing or delivering the site, harmless against any losses, liabilities, claims, expenses (including legal fees) in any way arising from, related to or in connection with your use of our website, your violation of the Terms, or the posting or transmission of any materials on or through the website by you, including but not limited to, any third party claim that any information or materials provided by you infringe upon any third party proprietary rights.
Entire Agreement
The Terms and any documents expressly referred to in them represent the entire agreement between you and us in relation to the subject matter of the Terms and supersede any prior agreement, understanding or arrangement between you and us, whether oral or in writing. Both you and we acknowledge that, in entering into these Terms, neither you nor we have relied on any representation, undertaking or promise given by the other or implied from anything said or written between you and us prior to such Terms, except as expressly stated in the Terms.
Termination
We reserve the right, in our sole discretion, to restrict, suspect, or terminate these Terms and your access to all or any part of the Site or the Content at any time and for any reason without prior notice or liability. We also reserve the right to cease providing the Site or the Services at any time.
Waiver
Our failure to exercise or enforce any right or provision of the Terms will not constitute a waiver of such right or provision. A waiver by us of any default will not constitute a waiver of any subsequent default. No waiver by us is effective unless it is communicated to you in writing.
Severability
If any of the provisions of the Terms are determined by any competent authority to be invalid, unlawful or unenforceable, such provision will to that extent be severed from the remaining Terms, which will continue to be valid and enforceable to the fullest extent permitted by law.
ADA Compliance Notice
We are committed to making the website’s content accessible for all. If you are having difficulty accessing, viewing and/or navigating any content on the website, or if you notice any content, feature or functionality that you believe is not fully accessible to people with disabilities, please contact us using the information provided on the contact page of our website using “Website Access” as the subject. Please provide a description of the feature you feel is not fully accessible or a suggestion for improvement. We will use it to accommodate all our customers and improve our overall accessibility policies.
Questions or Concerns
Please send all questions, comments and feedback to us using the information provided on the contact page of our website.

#### Thank You
Thank you for your request!  A member of our team will be in touch with you shortly.
Dr. Elias Darido

#### Thank You
Thank you for your request!  A member of our team will be in touch with you shortly.
Dr. Elias Darido

#### The Future of Bariatric Surgery
An excerpt from an interview conducted with Dr. Mason, the father of bariatric surgery. The entire interview is published in Surgery of Obesity and Metabolic Disorders (SOARD), volume 11, issue 2, pages 286-287. In this editorial, Dr. Mason endorses gastric fundus invagination as a potential replacement of sleeve gastrectomy. Gastric Fundus Invagination (GFI) also known as Sleeve Gastrotomy is a novel weight loss procedure designed and developed by Dr. Darido. Gastric fundus invagination has many advantages including reversibility, simplicity, and safety.
Interviewer: “What do you envision the future of bariatric surgery will be?”
Dr. Mason: “Sleeve gastrectomy is becoming the current operation of choice. Unfortunately, sleeve gastrectomy is more complex and irreversible. Epidemics of obesity and type-2 diabetes have spread to adolescents and children. Fortunately, Elias [3], and co-workers [2,3] have shown in rodent and growing porcine models that the ballooning portion of the stomach can be invaginated rather than resected [2,3]. The invaginated fundus is anastomosed internally to the antrum, fundic invagination could be called a sleeve gastrotomy, since it is to sleeve gastrectomy as gastric bypass is to gastric resection. My goal for gastric bypass was to “Keep it simple, surgeon” _and be reversible. I envision sleeve gastrotomy as the operation of choice for all ages and times. However, this procedure has not yet been evaluated in humans.”
Dr. Mason continues to say: “Darido’s sleeve gastrotomy (fundic invagination) should be as successful as sleeve gastrectomy. My original goal of decreasing the need for stomach resection will again be fulfilled. Complete stomachs will remain available by a simple reversal operation if needed later in life to provide digestion, dilution and perhaps normal dumping with greater knowledge and the cohesion of paradigms. “Scientific Discipline Will Replace Empiric Craft.” My mentors, Owen and Sara Wangensteen, used this in a subtitle for their history ofsurgeryin1978 [5]. Thank you for the honor of speaking at this meeting and thanks to all of those who made this possible. A special thanks to Elias Darido and coworkers for their imagination of invagination with internal anastomosis of the fundus to the antrum. Save the stomach, using education, scientific study and clinical translation. Keep it simple, surgeon. “
Edward E. Mason, M.D., F.A.C.S.
Emeritus Professor of Surgery, University of Iowa School of Medicine Iowa City, Iowa
 
References
[2] Darido E, Overby D W, Brownley K A, Farrell T M. Evaluation of gastric fundus invagination for weight loss in a porcine model. Obes Surg 2012;22(8):1293–7.
[3] Darido E, Moore J R. Comparison of gastric fundus invagination and gastric greater curvature plication for weight loss in a rat model of diet- induced obesity. Obes Surg 2014;24(6):897–902.
[5] Wangensteen O, Wangensteen S. The rise of surgery. From empiric craft to scientific discipline. London: Dawson Company, 1978.
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#### Travel & Accommodations
Many of our patients come from outside the Houston metro area. Houston is home to the world-renowned Texas Medical Center. To assist those patients traveling here, we have compiled a travel and hotel information guide. Our knowledgeable staff can often help you make your trip more affordable and enjoyable.
[vc_custom_heading text="Houston's Airports" use_theme_fonts="yes"]Houston Intercontinental Airport – international and domestic travel, located in north Houston, 45-minute drive to our office.
Houston Hobby Airport – domestic and local travel, located in southwest Houston, 30-minute drive to our office.
Private Transportation to and from the airports can be booked online with Transporter Houston
[vc_custom_heading text="Online Reservations" use_theme_fonts="yes"]
Orbitz
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Expedia
Cheapflights

Travelzoo
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[vc_custom_heading text="Houston hotels near our clinic" use_theme_fonts="yes"]Crowne Plaza – Houston River Oaks
2712 Southwest Freeway | Houston, TX 77098
​(713) 523-8448
Offering special discounted rates for our patients.
DoubleTree by Hilton Hotel Houston – Greenway Plaza
6 E Greenway Plaza
Houston, TX 77046
(713) 629-1200
Rates: Approx $104/night
Residence Inn Marriott- Houston Medical Center/NRG Park
7710 South Main Street
Houston, TX 77030
(713) 660-7993
Medical Rates: $119-129
Crowne Plaza Hotel- Medical/Reliant
8686 Kirby Drive
Houston Texas 77054
(713) 795-8416
Medical Rates: $80-90
Springhill Suites – Medical Center/NRG Park
1400 Old Spanish Trail
Houston, Texas 77054
(713)796-1000
Medical Rates: $119-129
Holiday Inn- NRG Area / Medical Center
8111 Kirby Drive
Houston, Texas 77054
(713)790-1900
Medical Rates: $85
Courtyard by Marriott Houston Medical Center/NRG Park
7702 Main Street
Houston, TX 77030
(713) 668-4500
Medical Rates: $119-129
Drury Inn & Suites Galleria
1615 West Loop
Houston, TX 77027
(713) 963-0700
Medical Rate: $99
Hampton Inn & Suites – Houston Medical Center – NRG Park
1715 Old Spanish Trail
Houston, TX 77054
(713) 797-0040
Medical Rate: $119-129
Comfort Suites Medical Center/NRG Stadium
1055 McNee Road, East of Main Street
Houston, TX 77054
(713) 668-1436
Medical Rates: $85

#### Weight Loss Insurance Check
Let our insurance specialists find out whether your insurance plan covers weight loss surgery. Simply complete the form and a member of our team will get back to you within 24 hours.

[vc_empty_space height="22px"]• Insurance & Financing Info
• About Dr. Darido
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#### Weight Loss Surgery Candidates
The NIH (National Institute of Health) established the following criteria for surgical consideration:

BMI ≥ 40, or more than 100 pounds overweight.
BMI ≥ 35 and at least two obesity-related co-morbidities such as type II diabetes (T2DM), hypertension, sleep apnea and other respiratory disorders, non-alcoholic fatty liver disease, osteoarthritis, lipid abnormalities, gastrointestinal disorders, or heart disease.

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#### What is Weight Loss Surgery?
Weight Loss Surgery

Houston Weight Loss Surgery Center offers a number of weight loss procedures. Dr. Darido insists on offering the surgery that is most effective for each patient. Weight loss surgery is not about making the stomach small and forcing the patient to eat less. The history of bariatric and weight loss surgery has taught us that anytime we “force” a patient to eat less in order to loose weight we fail. A successful weight loss procedure is a metabolic procedure. A metabolic procedure alters certain hormones that affect body weight, appetite and satiety, as well as energy metabolism.
Gastric bypass, Gastric Sleeve Surgery  and Duodenal switch are metabolic surgeries. For example, Ghrelin, a hunger hormone secreted by the stomach, decreases after gastric bypass and gastric sleeve surgery . For this reason, gastric bypass and gastric sleeve patients report increased satiety and decreased hunger. Ghrelin is only one of hundreds of hormones that change after a successful weight loss surgery. Lap band, intra-gastric balloon placement and gastric plication are restrictive procedure with no metabolic effect. Most lap band patients do not report hunger control. The success rate for restrictive procedures with no metabolic effect is very low. For this reason, Dr. Darido does not recommend lap band, gastric plication or intra-gastric balloon placement.
By the same token, diet and exercise programs fail to offer long-term weight loss for patients with severe obesity. When a person looses weight by diet and exercise, Ghrelin (hunger hormone) increases. An increase in ghrelin level stimulates a person’s appetite. This in turns leads to increased food consumption, which results in weight regain. This is the reason why so many diet regimens like jenny Craig and others fail to achieve durable weight loss.
At Houston Weight Loss Surgery Center, we spend lot of time educating our patients.“ Weight loss is a life long journey; it does not start and end with the surgery itself,” says Dr. Darido. Bariatric surgery by itself cannot permanently cure obesity. Adopting a healthy lifestyle, light and fresh diet, moderate daily exercise and a positive outlook on life will insure wonderful long-term results for health and weight.
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#### Your Weight Loss Journey
Houston Weight Loss Surgery Center is committed to making your weight loss journey as smooth as possible.
Step 1.
Your journey starts by completing a consultation request form (provided on this page) and scheduling a comfortable and private consultation with Dr. Elias Darido. Before the visit, you will be asked to fill out several forms about your health. These forms include questions about your medical history, diet history, previous surgeries, medications you take and allergies. You will be weighed and measured to calculate your BMI. You will then meet Dr. Darido to discuss your medical condition, talk about obesity and its causes, discuss lifestyle changes and determine the best weight loss solution for you. Dr. Darido will answer all your questions about bariatric surgery. He will go in detail over the different procedures. He will talk with you about the advantages and disadvantages of each procedure, and how much weight loss to expect. Dr. Darido will also discuss the risks of the surgery and the tests needed prior to surgery. Your consultation will last about one hour. Before you leave, you will be able to sit down with our insurance specialist to determine your insurance requirements.
Step 2.
Upper endoscopy, EKG, and basic blood tests are ordered in preparation for surgery. The purpose of upper endoscopy is to visualize the lining of your stomach and make sure there are no inflammation or lesions that need to be addressed prior to surgery. Upper endoscopy is especially helpful in patients who report acid reflux symptoms to check for a hiatal hernia. If present, Dr. Darido will fix the hernia during your bariatric procedure.
Step 3.
Houston Weight Loss Surgery Center nutritionist offers a comprehensive dietary evaluation. You will learn about diet changes you can expect after surgery and how to maintain a healthy and successful weight loss. In addition, our dietician will plan a high protein low calorie liquid diet for 2 to 3 weeks prior to surgery to shrink your liver, which will make your surgery safer.
Step 4.
Medical clearance is requested to make sure you are able to tolerate general anesthesia and surgery. You may need a sleep study to check for sleep apnea or a cardiac evaluation. You will also have a gallbladder ultrasound to check for gallstones.
Step 5.
A second visit with Dr. Darido will be scheduled when the bariatric coordinator has received all the results of all the tests and consultations requested. If everything is in order, you will be scheduled for surgery. You will sign consent for surgery, and you will receive your pre and post-operative care instructions.
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