Esophageal function in weight loss surgery

This is an article I wrote for the NYU weight management program newsletter a couple of years ago: I updated it a little.

We have only one esophagus so we have to be really good to it. The esophagus has one job- to squeeze whatever we swallow down to our stomach. The esophagus is a muscular tube which is important to remember. A muscle when used repetitively or when stress is placed on it, can fatigue. So what does that mean? Let’s look at a muscle that we can control like our bicep. We lift a 5 lb weight and after 20-30 repetitions, our bicep gets tired or worn out (I know for some of you superfit people, it may be 50 repsJ). This is important to remember for life with the gastric sleeve and gastric band especially after the band is adjusted.

Another fun fact about our esophagus? The esophagus is more constricted in the morning which means it feels tighter! It also means that the esophagus is “generating a higher pressure” or squeezing more first thing in the morning. Do you feel tighter in the mornings? Can’t get that coffee down first thing? Well that’s normal it turns out! When the esophagus squeezes so hard, it gives you the feeling of something being stuck or of chest pain in the middle of your chest. This has a lot of correlation for patients with gastric banding and also immediately after gastric bypass or sleeve gastrectomy.

The effect of that tightness is magnified when there is a band in place or right after vertical sleeve or gastric bypass. Imagine that your esophagus has to squeeze harder to get food or liquids that you swallow across the band or through the sleeve. The esophagus squeezes and generates a high pressure to get the swallow across the band and into the stomach because the band causes a high-pressure zone where we put it.

Specifically for the band:  When you get a band fill, the esophagus has to squeeze a lot harder to get what you swallow across the band. Many of you notice that you are tighter right after a fill, and then we often hear that the band “loosened”. Well what really happens is right after the fill, your esophagus feels tighter because it’s squeezing to some high pressures. And after a period of time, the esophagus figures out that it doesn’t have to squeeze as hard to get swallows across the band (Fig. 1). The pressure that the esophagus generates doesn’t go down to the same level as before the fill, it stays a little higher. A fill can be too tight because the esophagus CANNOT generate a high enough pressure to get your swallow down (this can be liquids, solid or even your own saliva). Right after a fill, we ask you to be on liquids for two days and puree for two days so that you don’t have a crisis, SUFFER and need an emergency “unfill”. Following liquids and puree format also gives your esophagus a chance to ease into the fill and doesn’t force your esophagus to generate super high pressures. The goal of fills is to try and find a balance between you not being hungry and being able to eat a variety of foods including protein and your esophagus not having to squeeze too hard.

Now, with the gastric sleeve, gastric bypass and lap band: If you take a big bite and swallow it, the esophagus has to squeeze harder. If you don’t chew your food well, the esophagus has to squeeze harder. If you take a bite and then take another one right away (we call it stacking the swallows), your esophagus has to squeeze harder. If you drink big gulps or chug a glass or bottle of water, your esophagus has to squeeze harder to get that bolus of liquids across the band into your stomach. So what you ask? Well remember that with repetitive use, any muscle can fatigue. When your esophagus gets tired- of all the gulping, and eating fast and not chewing well and trying to wash the food thru the band with liquids- ,it will stop squeezing so hard and be tired. When the esophagus doesn’t squeeze and give its’ all, the esophagus dilates. It can’t generate enough force to get food and liquids across the band, and this can cause esophagitis, reflux, heartburn, fluid coming out of your nose at night and night cough. Then what do we , the docs and clinicians, do? We loosen your band so that the esophagus doesn’t have to squeeze so hard, and it gets a chance to heal. For sleeve and bypass patients, eating behaviors have to change in order to get rid of that feeling of reflux.

Well, that sounds so simple right? Loosen the band, and let you heal! But some of you know that when we loosen the band, you get more hungry or you find that you can eat more. Perhaps the best way of avoiding loosening and dilating your esophagus IS…don’t take too big a bite, don’t stack your swallows (wait 30 seconds between bites ), don’t wash down your food with liquids. Your esophagus doesn’t get irritated because you swallowed too big a bite once, or that you gulped down a ½ liter of water once. It dilates because of repetitive behavior. We have all heard those touchy feely expressions: Be kind to one another or Be kind to the world, it’s the only one we have. Well I have a new one for you: Be kind to your esophagus, it’s the only one you got!