A Memorial Day Tribute

I friend of mine told me this true story yesterday and I wanted to share it with you as a tribute to all the men and women who have served in our armed forces and have fought and often died for the freedom we continue to enjoy in America.


My friend was teaching in the Ukraine several years ago while it was still part on the Soviet Union. It was very cold that February day and several street musicians and homeless people had taken refuge from the cold in the subway. As my American friend and his Ukrainian guide entered the subway one of the street musicians began to play the Star Spangled Banner.

My friend was shocked that he was so easily recognized as an American so he asked his guide, “If I changed into Ukrainian clothes do you think I would still be recognized as an American?” The guide quickly responded ”Yes, of course.” When he was asked why the guide said, ”Because you walk like you have had 200 years of freedom.” My friend will never forget that reply. It brought tears to his eyes even as he shared the story with me.


I what to thank my father, Dan Myers, for serving in the Navy during the Korean Conflict and my nephew, Jordan Boucier, for serving in Afghanistan and all of the wonderful men and women that serve in our military. Today I would especially like to remember all those that have given their lives that we may continue to walk like we have had “200 years of Freedom”.

On this memorial day let us not forget the immeasurable cost of that freedom.

Dr. Myers, Explain to Me the Analogy You Use about Storing Calories in the Pantry and the Cellar

First Burn the Calories in Your “Pantry” so You Can Begin to Use Up the Fat Calories Stored in Your “Cellar”
I often use this analogy to help people to understand what they can do to use up the calories they have stored as fat.
Humans store calories in two ways.
First we have a limited amount of storage in an animal form of carbohydrate called glycogen. Glycogen is very similar to starch and it stores calories by linking sugar molecules end to end. This is stored primarily in the liver and muscles so that energy is rapidly available in these organs in case of an emergency. I call these energy storage locations a person’s” pantry” since it is most readily available.
Our bodies prefer to “burn” the energy held in the sugar molecules. Therefore when energy is needed the first location the body goes to for energy is to the “pantry” where the attachments between the sugar molecules are broken and the individual sugar units are released to enter into the body’s machinery as fuel. This is very much like burning the wood in a wood stove for your first selection for heat.
Secondly we all know we store our calories as fat.
After about 2 or 3 days of fasting the body uses up the relatively small amount of glycogen stored in the “pantry” and must seek other fuel sources when it has used up the glycogen stores. This is when the body turns to the fat stored in the fat cells which I will refer to as calories stored in the “cellar”. This is somewhat like turning of the oil furnace once you have used up all of the wood for your fireplace.
In other words, the body does not start to burn fat stored in the long term storage location or the body’s “cellar” for fuel until the short term storage in the “pantry” is depleted of sugar calories.
The reason obesity occurs is that when we do not allow ourselves the use up the calories in the “pantry” to get to the long term storage of and we eat more calories than we use we not only fill up the pantry” to overflowing but as we keep adding more to the fat stores with every meal.
If someone goes on a diet or has bariatric surgery and for a time are not eating as many calories as they are expending , they continue to use all of the calories stored in the “pantry” and then they will begin to burn fat for fuel.
Another term we use when a person burns fat for fuel is ketosis. This is because most of the fat we store is stored as triglycerides which has a backbone of 3 carbon atoms, (thus the part of the word tri), each with attachments or long trailing lengths of stored calories called glycerides. A glyceride is made up of many two carbon fragments also called ketone bodies. When we start to burn fat for fuel the ketone bodies are separated from the rest of the glyceride and the ketone bodies circulate in our blood stream until they are picked up by the body’s energy forming machinery to be runt for fuel.
We even breathe out the ketone bodies and our breath may be fruity or musty when we are in ketosis. Once we are in ketosis and burning fat for fuel we want this to continue so we will lose our fat mass and therefore lose weight.
However if we stop the diet and or otherwise consume allot of carbohydrates the fat burning will stop and before we will not burn any more fat until we will again use up the carbohydrate calories we have just stored in our “pantry” and we can again switch over to burning fat for fuel.
Hopefully now you understand why I explain to my patients they should “use up the calories they are storing in their “pantry” so they will be able to start to burn the fat for fuel they have stored in their “cellar”!

Dr. Myers, Thanks for the Broken Finger!

Greetings Dr. Myers,
I just wanted to say, thanks for the broken finger. Sound odd? Silly, perhaps, but let me explain. (This is kind of long…sorry!)

Last week and this week here in Columbus is the annual Bike to Work Challenge. Never before would I even have considered such a thing – me, not just ride my bike approximately 13 miles downtown to work, but logically, home at the end of the day? So, I made the commitment this year to do it at least once. Children’s Hospital has a nice-sized group of cyclists that bike to work frequently, so there were experienced cyclists to buddy up with so that I wouldn’t have to make the trek alone.
Because I was hesitant to undertake such a thing with relative strangers, I tested the route on the Sunday before my scheduled Monday trek with coworkers, to make certain that I was up to the distance, etc. I made the trip downtown with no problems. I didn’t have a huge amount of time to give to this effort on a busy Sunday, so I immediately turned around and headed home to make certain that I was familiar with the route switches in the downtown area. George picked me up at Ohio Stadium so that we could get along with the rest of our day. So, I knew that the distance was totally doable and that I was comfortable with the sections when I would have to ride on the city streets.
Well…I overslept on Monday morning and woke up with only 30 minutes to shower, get my work clothes into a backpack and meet my fellow employees by the scheduled time…plus it was only 37 degrees at the time. It would have been SO easy to just make the phone call and say “Not going to make it, go ahead without me,” which is so in keeping with what I would expect of myself. Well, made it…hair blown dry and everything. Met everyone along the trail at the scheduled times and locations and was changed and at my desk in time to start the day.
Fast forward to the end of the day, and the small group of 4 that I had finished the ride with that morning had changed to include two men that I had never met and a coworker that I know slightly from our IS department (she would qualify as a runway model). So, our group of six, four of them very experienced riders, take off together. Approximately a mile from work, one of the veteran riders wipes out in front of me and I go head over heals over her. All I could think of was that I was going to break her in half, break every rib in her tiny body, or snap her leg (well, that and my dental work). After our four coworkers and a stranger who was also biking on the trail untangled us (literally, I had a handlebar caught totally up my pants leg) we were able to check for damage to self and bicycles. My coworker had quite the bloody gashes on her knee – but with her experience, had a first aid kit. There was much discussion by our coworkers about whether or not we should call for a ride, if they should ride to their end point and come back with their truck, etc. My preference was to get back up on my bike and go; which we did, after making certain that our bikes were road worthy.
I made it back to my starting point of Antrim Park, only a few minutes later than expected, knowing that I was sporting a broken pinkie finger on my right hand, but little else (which turned out to be incorrect – at home I discovered some decent scrapes and bruises across both thighs – I’m grateful that I don’t bruise much, it would have been a disgusting sight, otherwise).
So, at the end of the day:
• I didn’t roll back over in bed and say “to hell with it.”
• I rode my bike about 13 miles when it was only 37 degrees.
• I wasn’t mortified to be with relative strangers in stretchy work-out pants (NEVER bike shorts – puhleeze!)
• I got back “up on that horse” when it would have been easy (and perhaps better judgment) to call for a pick up.
• I did not shed a tear.
• I’m scheduled to do this twice again this week.

None of this is earth shattering, but all together, a big day for my psyche. Two years ago, I didn’t own a bike. I only bought a bike because I was getting one for George for his birthday and thought this would be fun to do together. Two years ago, I would NOT have dragged my rear end out of bed to ride a bike in 37 degree weather and if I had wiped out on said bike, you could have bet good money that I would have made a call for a pick up.

So, I’m thanking you for your part in all of this – broken pinkie and all. I’m extremely grateful for the wonderful care that you have provided and appreciate your calm…I think that I’ve learned a thing or two from you about patience, and much more.

Peace,
aph

Ann P. Holzapfel

New Video! Dietitian, Kristy Highley, RD Explains Nutrition for Bariatric Surgery Patients

Kristy Highley is a Registered Dietitian with a Masters Degree in Nutritian. She is a licensed dietitian in the state of Ohio. She primarily works with patients in the Fresh Start Bariatrics program at Riverside Methodist Hospital, Columbus, Ohio.

Can an Adjustable Gastric Band Develop a Leak?

If you do not feel restriction even after the band is adjusted repeatedly you could have a leak somewhere in the system.

Your surgeon may be able to determine that a leak has occurred by withdrawing the fluid from the band to see if the amount is about the amount that has been placed into the band over time. If necessary the radiologist or surgeon can inject contrast into the port and the x-rays can show where the system is leaking.

Actually it is quite rare to find a leak in a gastric band system. In fact I have only had this happen a couple of times over the years I have been placing gastric bands and in each occurrence it has been a leak from the tubing from where the access needle had punctured the tubing. To date this has only happened with the Lap-Band system in my practice. However, it is certainly possible to have leaks at other locations and with other products.

The band should be tested before it is placed into a patient so there should not be a leak as the device is placed into the abdomen. However there are several ways the device can be injured.

1). If the insertion of the device through the abdominal wall is difficult or if the insertion through the trocar that helps with the passage of the band into the abdomen is difficult, the balloon could be torn. Although a tear could be seen by the surgeon and/or assistant it is possible that it is not able to be seen.

2). The balloon could be torn or punctured also by an instrument or a needle as the band is placed around the upper stomach or by the needle as it is sutured into place. Unless it was noted at the time of the puncture it would be very difficult to see this problem.

3). The tubing is unlikely to be injured during placement of the adjustable gastric band but it certainly could be punctured by the needle used during an adjustment. This could occur as the surgeon is trying to access the port. If the needle punctured the tubing instead of the port the water that is placed into the port could leak out of the tubing puncture site, especially when additional fluid causes increasing pressure in the system which occurred in the original higher pressure Lap-Band. Also the connection in the Lap-Band port has an unprotected connection as the tubing leaves the port making it a fairly easy location to injure the tubing. In the Realize Band system the location where the port is connected to the tubing is protected from puncture by metal or hard plastic for about 1/2 inch. It is therefore less likely that the tubing will be punctured close to the port in the Realize Band system.

4). One other possible leak from a Lap-Band system is at the steel connector site where the tubing that leads to the band is connected to the tubing that leads to the port. This can occur as the steel connector is inserted into the tubing or it could occur several months or years later as the tubing becomes more brittle with age. This connector is not part of the Realize Band system and the tubing does not seem to become more brittle with time with the Realize Band material used for the tubing.

To repair a leak in the tubing or near the port the port and or a porting of the tubing will need to be removed and replaced. This is a relatively easy operation and does not require replacement of the band that was placed around the upper part of the stomach. However if the gastric band itself is leak in the band must be replaced.

Therefore, if you are not feeling the restriction you expect even after a few adjustments you should return to your surgeon and ask if a leak is a possible problem.

New Video on Exercise Therapy and Bariatric Sugery

Nicollette Henry explains how important exercise therapy has been for her and her family.

The Gastric Sleeve Operation is Now Covered By CIGNA.

The following statement was sent to me just yesterday:

"As of May 15, 2010, CIGNA has changed its position on reimbursement for sleeve gastrectomy, and will now cover the procedure. This coverage will be the same as the other bariatric surgery procedures covered by CIGNA."

This is great news for persons of size with CIGNA medical insurance that would prefer the gastric sleeve operation. CIGNA now joins Medical Mutual, United Health Care, Aetna, and Humana through OhioHealth as commercial payers that cover the gastric sleeve operation.

The only insurance companies in our area that have not yet approved coverage for this procedure is the Anthem/Blue Cross-Blue Shield insurance companies.

Dr, Myers, Could You Share More Details About the Gastric Sleeve Operation?

I recently was asked several questions about the details of performing a Gastric Sleeve procedure which is also called a vertical sleeve gastrectomy, (VSG), or just a sleeve gastrectomy. I relied by email but I think it would be of interest to others as well.

A Gastric Sleeve was first performed as a portion of a more complicated operation called a Duodenal Switch. This operation was modified and popularized by Dr. Douglas Hess from Bowling Green, Ohio. In this operation an intestinal bypass or switch was performed as well as reducing the size of the stomach with the formation of a tube of stomach formed along the inner curvature of the stomach wich we now call a gastric sleeve.

As our technology advanced bariatric surgeons began to perform the duodenal switch operation using less invasive techniques. Several small incisions were made to pass the instruments through and a laparoscope was used to visualize the inside of the abdomen.

However, a duodenal switch operation has higher risks and a higher mortality as well especially in excessively heavy patients. In an attempt to decrease these risks Dr. Micheal Ganger began to stage the two portions of the operation by doing the gastric sleeve portion of the operation at the time of the initial operation, allowing the patient to lose some weight before returning at a later time to perform the intestinal switch portion of the operation.

What he observed was that often the patient had lost so much weight from the first portion of the operation that they did not need to have the second phase of the operation.

Over time the Gastric Sleeve has been chosen as a primary bariatric operation even for patients who meet criteria for bariatric surgery but are not excessively heavy.
The operation has also been refined so that the diameter of the gastric sleeve has decreased in size and the operation has become even more successful. Now the volume of food a person can eat after a Gastric sleeve operation is about ¾ of a cup of food.

I will now share some technical aspects of the operation that I perform.
Different surgeons use different devices to size the diameter of the sleeve. Most surgeons probably use a bougie, (the French word for candle), which is a tapered dilator that is passed through the mouth after the patient is asleep. This is passed into the stomach and along the inner curve of the stomach so that the tube of stomach called the sleeve is tapered over the bougie. The size of the bougie varies but generally has decreased from a 60 French diameter which is nearly an inch in diameter to a 32 French which is about 1/3 of an inch in diameter.

I use a 9 mm gastroscope that is 32 French for a sizer instead of a boogie since it is easier to direct and to place and I can examine the inside of the sleeve for size and to make sure there is no bleeding or kinking after the sleeve has been completed. I leave a little space between the scope and the staple line to avoid kinking or twisting of the sleeve as well.

The rest of the stomach is removed by disconnecting the blood supply and any other connections to the portion of the stomach that is to be removed and using a linear stapling device to create a long staple line beginning about 5 cms, (2 inches), from the outlet of the stomach called the pylorus. I also taper the lower portion of the stomach which is called the antrum to make sure to stomach that is left is not too large. The staple line is then continued all the way up toward the inlet of the stomach called the gastro-esophageal junction being as careful as possible to leave a little amount of space so as not to staple onto the esophagus if possible.

This long staple line staples across the blood vessels that are necessary to keep the stomach left behind healthy. However, this means that there is some risk of bleeding from this staple line. To decrease the risk of bleeding along the staple line surgeons use one of a couple of techniques. Some surgeons oversew the staple line with a long running stitch. Others may suture selective points along the staple line. I have chosen to reinforce the staple line with buttress material that is made from bovine pericardium which is loaded onto the stapling device prior to inserting the stapler into the abdomen so there is no need for overseeing. This also reduces the actual operating tine to usually 1 hour or less.
In the usual patient the patient has three 5 mm incisions, (less than ¼ inch), and one 2 cm incision, (less tan an inch), and this slightly larger incision is usually hidden within the skin of the umbilicus or belly button.

I have been performing the Gastric Sleeve operation since October of 2007 and have performed over 100 of these operations. On the average our patients are losing over 70% of their excess weight at 1 year after surgery and they are very pleased with their outcomes.

I think we have learned something about bariatric surgery as well. All operations that are commonly used to help persons of size lose their excess weight reduced the size of the stomach. This is true for a gastric band, gastric bypass, gastric sleeve and a duodenal switch. Reduction in the size of the stomach is an important common theme. We have found that the amount of weight loss and the speed of that weight loss is very similar between the gastric bypass and the gastric sleeve.

My conclusion is that they both reduce the size of the stomach but have different ways of connecting the small gastric pouch to the rest of the gastrointestinal track. Except for the decreased absorption of vitanins and minerals I now believe there is very little difference in these two operations. I feel the intestinal bypass or duodenal switch part of these operations do not contribute as much as we once thought and the decreased size of the stomach is probably the most important part of these operations. The intestinal bypass or switch portion of bariatric operations contribute to the difficulty in absorbing vitamins and minerals without contributing all that much to the weight loss.

What Do You Think is the Best Way to do Band adjustments?

First, the goal of adjusting a band is for the patient to lose between 1 to 2 lbs. a week with the patient not experiencing hunger for about 3 hours after a solid meal. Of course we do not want the patient to be vomiting or experiencing acid reflux which could indicate that the band may be too tight. If the patient is not losing between 1 to 2 lbs. per week and is hungry between meals an adjustment should be considered.

Bariatric surgeons use several different methods of “filling” adjustable gastric bands.



Some surgeons use a standard volume for each fill without regard to how well the pouch is emptying. They will usually have the patient swallow water before leaving the office to make sure the band is not too tight.

Other surgeons make adjustments under Flouroscopy. In this situation saline is injected into the port to adjust the outlet of the pouch above the band while the patient swallows a chalky liquid. An x-ray machine called a fluoroscope allows the surgeon and/or radiologist to view the liquid as it travels down the esophagus and through the outlet of the gastric pouch into the rest of the stomach. Based on how quickly the fluid empties, the band can be adjusted to change the rate of emptying. This requires doing the adjustment in the Radiology Department or by using expensive x-ray equipment in the office. And this approach exposes the patient to radiation with each adjustment.

The method I have chosen is called a “water test”. With each adjustment I temporarily overfill the band and have the patient sit up and swallow cold water. This will make the water back-up in the esophagus causing a pressure sensation in the chest like the feeling of needing to burp. I adjust the band by removing some of the fluid from the band until the water is released from the pouch and the esophagus. When the patient can drink water without difficulty the adjustment is complete. This allows the adjustment to be made in the office with a high degree of certainty that the adjustment is correct. Also the patient is not exposed repeatedly to radiation.

I have been very pleased with this method. In fact we have achieved an average of 63% loss of excess weight in just one year for those band patients who see us each month in the office for evaluation. Of course, patients do not need an adjustment each time as long as they are meeting their goals.

Finally back from Italy!

Welcome from New York City! I am finally back from Italy and in the United States. However, I am delayed in getting back to Columbus, Ohio making it necessary to inconvienience the 3 patients who were scheduled for surgery today. Yesterday our flight from Pisa, Italy was delayed several hours because of the volcanic plume from the volcano in Iceland. Then to avoid the plume we were routed up over Norway and down over Canada to get to New York. Therefore the time of the flight was 14 hours instead of the expected 9 hours and 50 minutes. On top of that as we were about to land we were told the flaps on our plane were not working and they called out the fire trucks and ambulances "just in case". We landed safely with our family but missed all connecting flights and spent the night in hotel rooms. We should be leaving for the JFK Airport in a couple of hours. Traveling with the family including three kids 5 years, 3 years and 10 months is a challenge especially when all three kids lost their lunch on the landing. We all smelled great getting off the plane! Actually the kids were amazing during the entire vacation and all 12 of us had a great time in Italy.


We ahd a great time exploring Florence, visiting the beautiful mideavil city of Seina and even taking a day trip to the coast at the Cinque Terre. The food was great and always interesting. We stayed at a vineyard outside of Florence and also visited another family vineyard in the Chianti region were we had a wonderful meal with their family.

Returning to the USA today I find one very striking difference. The rate of obesity is much higher in our country. In fact, despite the wonderful food in Italy I saw only one person out of the thousands of people I saw there that would have met criteria for bariatric surgery and at breakfast this morning at our Hampton Inn I noticed at least 6 of the 30 or so people at breakfast would meet criteria for bariatric surgery. I am afraid all of the gains we have made in heart and cancer care will be lost as the obesity epidemic continues to increase the suffering Americans are experiencing from obesity related medical problems.
I return committed to care for as many people suffering from the effects of obesityt as want to be helped by means of bariatric surgery.

While reading the USA Today this morning I read a quote that is true not only for business but for my patients as well. Mark Zuckerberg, the CEO of Facebook said "When the would is moving and changing so fast, the worst risk is to do nothing". We have enjoyed our vacation but it is time for me to get busy helping those that want to be helped from this devastating problem.