Dr. Myers, Why Do I Sometimes Feel Squeezing Pressure in My Chest When Eating or Drinking?

Squeezing pressure in the chest can be a symptom of several problems such as heart disease, gallbladder disease or pressure in the esophagus. If you think the symptoms may be related to your heart call your primary care doctor or go to the emergency room.

However, if this is happening to you several weeks or months after having a bariatric operation it is likely to be esophageal pressure from eating or drinking faster than the pouch or sleeve is emptying thus food, drink and or air is accumulating in the esophagus. The esophagus squeezes the food trying to get it out of the esophagus and into the stomach. However, if the pouch is full the food in the esophagus has nowhere to go. Although there are minimal pain fibers in the stomach, the esophagus is exquisitely sensitive to pressure and will definitely let you know when it cannot move food or drink into the stomach.

This can happen regardless of whether you have had a gastric bypass, gastric sleeve procedure or an adjustable gastric band operation.

In this situation the worst thing you can do is to try to get the food moving by drinking more. This just adds to the problem by adding more fluid into the esophagus and makes the pain more severe. The pain lasts even longer since the additional food or drink also has nowhere to go.

Throwing up what is in the esophagus can give you relief but if you are patient usually the food and drink is likely to pass through the exit of the pouch or sleeve and the pain will be relieved.

After bariatric surgery, eating and drinking too fast should be avoided and may cause squeezing chest pain. When it occurs after eating it may be a possible sign that you may have just eaten too much too fast for the length of time it takes for the food in the pouch or sleeve to pass. In band patients continuing to experience this problem may lead to band slippage. (See band slippage elsewhere in this blog.)Reviewing the “Rule of 30’s” in this blog can help you to avoid this symptom.

Of course, if you have any consern that this is not related to eating too fast call your doctor or go to an emergency room to make sure the pain you are experiencing is not related to your heart.

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8 Rules for Longterm Success After Bariatric Surgery

1). NO FLY ZONE
Identify your food triggers. Those foods that are very difficult for you stay away from. If you are like me it is the cookies. For others it may be pizza or soda. These foods should not be brought you’re your home or onto your property. Your property should be a NO FLY ZONE for these foods; “they just don’t fly here “ Find suggestions like these in the great book, Exodus from Obesity.

2). PLAN BEFORE YOU ATTEND
Before attending a wedding or another special event where you know food will be a major part of the event make sure you plan ahead. Plan what you will eat and drink and what you will stay away from.

3). SOLIDS FIRST
Start with solids, especially protein, before you move on to other foods. This will make sure you get the most important foods in first and there will be less room for high calorie carbohydrates.

4). AVOID CALORIE CONTAINING LIQUIDS
Cream soups, ice cream, milk, soda and other high calorie liquids should be avoided. Regardless of which operation you choose, liquids will move through the pouch, band or sleeve without resistance and all those calories will be absorbed very quickly. These high caloric liquids can blunt your weight loss and keep you from reaching your goals.

5). RULE OF 30’S
Chew 30 times before swallowing, wait 30 seconds between bites and wait 30 minutes after completing a meal befor taking most of your liquids.
6). SMALL PLATES DEVIDED IN 4 QUADRANTS
Choose a small plate for your meals and visualize the plate being divided into 4 quadrants. One quadrant for protein, (fish, meat or beans), One for starch, (bread, rice, potatoes, corn or carrots) and then the other two quadrants should be for green vegatables.

7). STAY ACTIVE
Make arrangements for 30 to 60 minutes of vigorous exercise 3 to four days per week.

8). WEIGH YOURSELF AT LEAST EACH WEEK
Those who weigh themselves frequently are more likely to keep their weight off long term.

Difficulty Eating During the” Window of Misery”

I had a patient in the office today about 8 weeks out from her laparoscopic Roux en-Y gastric bypass. She had lost about 50 lbs and was concerned about having more difficulty eating some solid foods than she seemed to have just a few weeks ago. I explained the symptoms she is experiencing are fairly common for people 6 to 9 weeks after a gastric bypass. Some people call this time “the window of misery”. Although most patients will not be bothered by symptoms during this period of time, others will experience temporary difficulty.

When a gastric bypass operation is first performed I use a 25 mm circular stapler to make the connection between the gastric pouch and the small intestine so the outlet size is consistent. Initially the connection is about the size of your thumb and there is minimal resistance to food and drink. The connection heals by the body laying down scar tissue. As the healing process continues over the next several weeks, more scar tissue forms and the scar contracts making the outlet of the pouch become smaller. Eventually between 6 and 9 weeks, during the “window of misery”, the size of the outlet is only the size of the tip of your little finger or even less.

Because the outlet is so much smaller there is more resistance to the food passing through the new opening. Therefore to get food to pass it takes longer and the particle size may need to be reduced. In fact if a patient continues to try to eat and drink as they have in the first few weeks after their operation they can make themselves miserable. If they eat faster than the pouch can empty, the food and drink will back up into the esophagus and the will experience a squeezing pressure in their chest from the contractions of the esophagus trying to push the food through the smaller opening. This pain in the chest after eating means the patient is eating faster than the food is able to leave the pouch.

Fortunately, after about 9 weeks the scar will slowly mature. As the scar softens the outlet will become larger again allowing more food to pass more quickly. Over time the symptoms will become less frequent.

Nevertheless, even at 6 months it is likely that a patient will occasionally have difficulty with some foods such as bread, chicken or steak. Sometime between 6 and 12months even these foods will pass more easily.

About once a year in our practice the narrowing becomes so small it is difficult for anything to pass. This is called an anastomotic stricture meaning there is a severe narrowing or stricture at the anastomosis or connection between the pouch and intestine. If this happens the patient should have an upper endoscopy and a special balloon is passed to dilate the opening. After this is done the patient will be able to eat and drink normally the same day. This procedure can be performed without the patient staying in the hospital overnight.

But for most people if they are patient and take liquids with small particles until after 9 weeks following surgery they will not need a dilation and will get through this time without difficulty.

Dr. Myers, What Standards Help to Make Bariatric Surgery as Safe and Effective as possible?

We have designed standards into our bariatric surgery program that generates exceptionally low complication rates and outcomes that are about 20% better than reported averages. Some of these standards are listed below:

Since the risk to the patient increases with a BMI over 55, patients must be at a BMI of 55 or less prior to operation. If a patient’s weight exceeds this they should be treated medically to assist them in losing weight to reach a BMI of 55.

A Very Low Carbohydrate Diet is started several days before operation in non-diabetic patients and 2 weeks prior to operation is diabetics to decrease the size of the liver making it easier and safer to perform the bariatric operation.

We prevent blood clots from forming by using Lovenox, (a blood thinner), while in the hospital and for 6 days postop. We also require early walking the night of the operation and use compression garments to keep circulation flowing even while patients are resting in bed. For patients of higher risk they will be asked to have a special temporary filter placed in the vein returning blood from the lower half of the body back to the heart to prevent blood clots from reaching the heart and lungs.

Patients with a diagnosis of obstructive sleep apnea must be compliant with their CPAP for at least 3 weeks before their operation to alow their heart to become stronger and the CPAP level is adjusted where necessary to no more than 10 cms of H2O after surgery to prevent excess air in the gastrointestinal tract.

Blood pressure medicines called ACE inhibitors and ARBS are discontinued or decreased several days prior to surgery to make sure the patient’s blood pressure does not become too low during surgery.

Patients must stop smoking at least 6 weeks prior to operation. This decreases their risk of ulcer formation and decreases the risk of blood clots as well.

Patients must agree to participate in all of the components of Fresh Start Bariatrics and pay for the program prior to surgery. This helps to motivate them to complete the exercise and dietary portions of the program.

The patients proceed to insurance approval and on to surgery only after the dieticians, psychologist and medical personnel all agree that they are ready to proceed.

All of htese standards help to decrease risks and inprove longterm results.