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Pouch Rules for
Dummies
INTRODUCTION:
A common misunderstanding of gastric bypass surgery is
that the pouch causes weight loss because it is so small,
the patient eats less. Although that is true for the first
six months, that is not how it works. Some doctors have
assumed that poor weight loss in some patients is because
they aren't really trying to lose weight. The truth is it
may be because they haven't learned how to get the
"satisfied" feeling of being full to last long enough.
HYPOTHESIS OF POUCH FUNCTION:
We have four educated guesses as to how the pouch works:
1) Weight loss occurs by actually "slightly stretching"
the pouch with food at each meal or;
2) Weight loss occurs by keeping the pouch tiny through
never ever overstuffing or;
3) Weight loss occurs until the pouch gets worn out and
regular eating begins or;
4) Weight loss occurs with education on the use of the
pouch.
PUBLISHED DATA:
How does the pouch make you feel full?
The nerves tell the brain the pouch is distended and that
cuts off hunger with a feeling of fullness.
What is the fate of the pouch? Does it enlarge? If it
does, is it because the operation was bad, or the patient is
overstuffing themselves, or does the pouch actually re-grow
in a healing attempt to get back to normal?
For ten years, I had patients eat until full with cottage
cheese every three months, and report the amount of cottage
cheese they were able to eat before feeling full. This gave
me an idea of the size of their pouch at three month
intervals. I found there was a regular growth in the amount
of intake of every single pouch. The average date the
pouch stopped growing was two years. After the second year,
all pouches stopped growing. Most pouches ended at 6 oz.,
with some as large at 9-10 ozs.
We then compared the weight loss of people with the known
pouch size of each person, to see if the pouch size made a
difference. In comparing the large pouches to the small
pouches, THERE WAS NO DIFFERENCE IN PERCENTAGE OF WEIGHT
LOSS AMONG THE PATIENTS. This important fact essentially
shows that it is NOT the size of the pouch but how it is
used that makes weight loss maintenance possible.
OBSERVATIONAL BASED MEDICINE:
The information here is taken from surgeon's
"observations" as opposed to "blind" or "double blind"
studies, but it IS based on 33 years of physician
observation.
Due to lack of insurance coverage for WLS, what
originally seemed like a serious lack of patients to
observe, turned into an advantage as I was able to follow my
patients closely. The following are what I found to effect
how the pouch works:
1. Getting a sense of fullness is the basis of successful
WLS.
2. Success requires that a small pouch is created with a
small outlet.
3. Regular meals larger than 1 ½ cups will result in
eventual weight gain.
4. Using the thick, hard to stretch part of the stomach
in making the pouch is important.
5. By lightly stretching the pouch with each meal, the
pouch send signals to the brain that you need no more food.
6. Maintaining that feeling of fullness requires keeping
the pouch stretched for awhile.
7. Almost all patients always feel full 24/7 for the
first months, then that feeling disappears.
8. Incredible hunger will develop if there is no food or
drink for eight hours.
9. After 1 year, heavier food makes the feeling of
fullness last longer.
10. By drinking water as much as possible as fast as
possible ("water loading"), the patient will get a feeling
of fullness that lasts 15-25 minutes.
11. By eating "soft foods" patients will get hungry too
soon and be hungry before their next meal, which can cause
snacking, thus poor weight loss or weight gain.
12. The patients that follow "the rules of the pouch"
lose their extra weight and keep it off.
13. The patients that lose too much weight can maintain
their weight by doing the reverse of the "rules of the
pouch."
HOW DO WE INTERPRET THESE
OBSERVATIONS?
POUCH SIZE:
By following the "rules of the pouch", it doesn't matter
what size the pouch ends up. The feeling of fullness with 1
½ cups of food can be achieved.
OUTLET SIZE:
Regardless of the outlet size, liquidy foods empty faster
than solid foods. High calorie liquids will create weight
gain.
EARLY PROFOUND SATIETY:
Before six months, patients much sip water constantly to
get in enough water each day, which causes them to always
feel full.
After six months, about 2/3 of the pouch has grown larger
due to the natural healing process. At this time, the
patient can drink 1 cup of water at a time.
OPTIMUM MATURE POUCH:
The pouch works best when the outlet is not too small or
too large and the pouch itself holds about 1 ½ cups at a
time.
IDEAL MEAL PROCESS (rules of the
pouch):
1. The patient must time meals five hours apart or the
patient will get too hungry in between.
2. The patient needs to eat finely cut meat and raw or
slightly cooked veggies with each meal.
3. The patient must eat the entire meal in 5-15 minutes.
A 30-45 minute meal will cause failure.
4. No liquids for 1 ½ hours to 2 hours after each meal.
5. After 1 ½ to 2 hours, begin sipping water and over the
next three hours slowly increase water intake.
6. 3 hours after last meal, begin drinking LOTS of
water/fluids.
7. 15 minutes before the next meal, drink as much as
possible as fast as possible. This is called "water
loading." IF YOU HAVEN'T BEEN DRINKING OVER THE LAST FEW
HOURS, THIS 'WATER LOADING' WILL NOT WORK.
8. You can water load at any time 2-3 hours before your
next meal if you get hungry, which will cause a strong
feeling of fullness.
THE MANAGEMENT OF PATIENT
TEACHING AND TRAINING:
You must provide information to the patient
pre-operatively regarding the fact that the pouch is only a
tool: a tool is something that is used to perform a task but
is useless if left on a shelf unused. Practice working with
a tool makes the tool more effective.
NECESSITY FOR LONG TERM
FOLLOW-UP:
Trying to practice the "rules of the pouch" before six to
12 months is a waste. Learning how to delay hunger if the
patient is never hungry just doesn't work. The real work of
learning the "rules of the pouch" begins after healing has
caused hunger to return.
PREVENTION OF VOMITING
Vomiting should be prevented as much as possible. Right
after surgery, the patient should sip out of 1 oz cups and
only 1/3 of that cup at a time until the patient learns the
size of his/her pouch to avoid being sick.
It is extremely difficult to learn to deal with a small
pouch. For the first 6 months, the patient's mouth will
literally be bigger than his/her stomach, which does not
exist in any living animal on earth.
In the first six weeks the patient should slowly transfer
from a liquid diet to a blenderized or soft food diet only,
to reduce the chance of vomiting.
Vomiting will occur only after eating of solid foods
begins. Rice, pasta, granola, etc. will swell in time and
overload the pouch, which will cause vomiting. If the
patient is having trouble with vomiting, he/she needs to get
1 oz cups and literally eat 1 oz of food at a time and wait
a few minutes before eating another 1 oz of food. Stop when
"comfortably satisfied," until the patient learns the size
of his/her pouch.
SIX WEEKS
After six weeks, the patient can move from soft foods to
heavy solids. At this time, they should use three or more
different types of foods at each sitting. Each bite should
be no larger than the size of a pinkie fingernail bed. The
patient should choose a different food with each bite to
prevent the same solids from lumping together. No liquids 15
minutes before or 1 ½ hours after meals.
REASSURANCE OF ADEQUATE
NUTRITION
By taking vitamins everyday, the patient has no reason to
worry about getting enough nutrition.
Focus should be on proteins and vegetables at each meal.
MEAL SKIPPING
Regardless of lack of hunger, patient should eat three
meals a day. In the beginning, one half or more of each meal
should be protein, until the patient can eat at least two oz
of protein at each meal.
ARTIFICIAL SWEETENERS
In our study, we noticed some patients had intense hunger
cravings which stopped when they eliminated artificial
sweeteners from their diets.
AVOIDING ABSOLUTES
Rules are made to be broken. No biggie if the patient
drinks with one meal ? as long as the patient knows he/she
is breaking a rule and will get hungry early. Also if the
patient pigs out at a party? that's OK because before
surgery, the patient would have pigged on 3000 to 5000
calories and with the pouch, the patient can only pig on
600-1000 calories max. The patient needs to just get back to
the rules and not beat him/herself up.
THREE MONTHS
At three months, the patient needs to become aware of the
calories per gram of different foods to be aware of "the
cost" of each gram. (cheddar cheese is 16 cal/gram; peanut
butter is 24 cals/gram). As soon as hunger returns between
three to six months, begin water loading procedures.
THREE PRINCIPLES FOR GAINING AND
MAINTAINING SATIETY
1. Fill pouch full quickly at each meal.
2. Stay full by slowing the emptying of the pouch. (Eat
solids. No liquids 15 minutes before and none until 1 ½
hours after the meal). A scientific test showed that a meal
of egg/toast/milk had almost all emptied out of the pouch
after 45 minutes. Without milk, just egg and toast, more
than ½ of the meal still remained in the pouch after 1 ½
hours.
3. Protein, protein, protein. Three meals a day. No high
calorie liquids.
FLUID LOADING
Fluid loading is drinking water/liquids as quickly as
possible to fill the pouch which provides the feeling of
fullness for about 15 to 25 minutes. The patient needs to
gulp about 80% of his/her maximum amount of liquid in 15 to
30 SECONDS. Then just take swallows until fullness is
reached.
The patient will quickly learn his/her maximum tolerance,
which is usually between 8-12 oz.
Fluid loading works because the roux limb of the
intestine swells up, contracting and backing up any future
food to come into the pouch. The pouch is very sensitive to
this and the feeling of fullness will last much longer than
the reality of how long the pouch was actually full. Fluid
load before each meal to prevent thirst after the meal as
well as to create that feeling of fullness whenever suddenly
hungry before meal time.
POST PRANDIAL THIRST
It is important that the patient be filled with water
before his/her next meal as the meal will come with salt and
will cause thirst afterwards. Being too thirsty, just like
being too hungry will make a patient nauseous. While the
pouch is still real small, it won't make sense to the
patient to do this because salt intake will be low, but it
is a good habit to get into because it will make all the
difference once the pouch begins to regrow.
URGENCY
The first six months is the fastest, easiest time to lose
weight. By the end of the six months, 2/3 of the regrowth of
the pouch will have been done. That means that each present
day, after surgery you will be satisfied with less calories
than you will the very next day. Another way to put it is
that every day that you are healing, you will be able to eat
more. So exercise as much as you can during that first six
months as you will never be able to lose weight as fast as
you can during this time.
SIX MONTHS
Around this time, our patients begin to get hungry
between meals. THEY NEED TO BATTLE THE EXTRA SALT INTAKE
WITH DRINKING LOTS OF FLUIDS IN THE TWO TO THREE HOURS
BEFORE THEIR NEXT MEAL. Their pouch needs to be well watered
before they do the last gulping of water as fast as possible
to fill the pouch 15 minutes before they eat.
INTAKE INFORMATION SHEET AS A
TEACHING TOOL
I have found that having the patients fill out a quiz
every time they visit reminds them of the rules of the pouch
and helps to get them "back on track." Most patients have no
problems with the rules, some patients really struggle to
follow them and need a lot of support to "get it", and a
small percentage never quite understand these rules, even
though they are quite intelligent people.
HONEYMOON SYNDROME
The lack of hunger and quick weight loss patients have in
the first six months sometimes leads them to think they
don't need to exercise as much and can eat treats and extra
calories as they still lose weight anyway. We call this the
"honeymoon syndrome" and they need to be counseled that this
is the only time they will lose this much weight this fast
and this easy and not to waste it by losing less than they
actually could. If the patient's weight loss slows in the
first six months, remind them of the rules of water intake
and encourage them to increase their exercise and drink more
water. You can compare their weight loss to a graph showing
the average drop of weight if it will help them to get back
on track.
EXERCISE
In addition to exercise helping to increase the weight
loss, it is important for the patient to understand that
exercise is a natural antidepressant and will help them from
falling into a depression cycle. In addition, exercise jacks
up their metabolic rate during a time when their metabolism
after the shock of surgery tends to want to slow down.
THE IDEAL MEAL FOR WEIGHT LOSS
The ideal meal is one that is made
up of the following: ½ of your meal to be low fat protein, ¼
of your meal low starch vegetables and ¼ of your meal solid
fruits. This type of meal will stay in your pouch a long
time and is good for your health.
VOLUME VS. CALORIES
The gastric bypass patient needs
to be aware of the length of time it takes to digest
different foods and to focus on those that take up the most
space and take time to digest so as to stay in the pouch the
longest, don't worry about calories. This is the easiest way
to "count your calories." For example, a regular stomach
person could gag down two whole sticks of butter at one
sitting and be starved all day long, although they more than
have enough calories for the day. But you take the same
amount of calories in vegetables, and that same person
simply would not be able to eat that much food at three
sittings ? it would stuff them way too much.
ISSUES FOR LONG TERM WEIGHT
MAINTENANCE
Although everything stated in this
report deals with the first year after surgery, it should be
a lifestyle that will benefit the gastric bypass patient for
years to come, and help keep the extra weight off.
COUNTER-INTUITIVENESS OF FLUID
MANAGEMENT
I admit that avoiding fluids at
meal time and then pushing hard to drink fluids between
meals is against everything normal in nature and not a
natural thing to be doing. Regardless of that fact, it is
the best way to stay full the longest between meals and not
accidentally create a "soup" in the stomach that is easily
digested.
SUPPORT GROUPS
It is natural for quite a few
people to use the rules of the pouch and then to tire of it
and stop going by the rules. Others "get it" and adhere to
the rules as a way of life to avoid ever regaining extra
weight. Having a support group makes all the difference to
help those that go astray to be reminded of the importance
of the rules of the pouch and to get back on track and keep
that extra weight off. Support groups create a "peer
pressure" to stick to the rules that the staff at the
physician's office simply can't create.
TEETER TOTTER EFFECT
Think of a teeter totter suspended
in mid air in front of you. Now on the left end is exercise
that you do and the right end is the foods that you eat. The
more exercise you do on the left, the less you need to worry
about the amount of foods you eat on the right. In exact
reverse, the more you worry about the foods you eat and keep
it healthy on the right, the less exercise you need on the
left.
Now if you don't concern yourself with either side, the
higher the teeter totter goes, which is your weight. The
more you focus on one side or the other, or even both sides
of the teeter totter, the lower it goes, and the less you
weigh.
TOO MUCH WEIGHT LOSS
I have found that about 15% of the
patients which exercise well and had between 100 to 150 lbs
to lose, begin to lose way too much weight. I encourage them
to keep up the exercise (which is great for their health)
and to essentially "break the rules" of the pouch. Drink
with meals so they can eat snacks between without feeling
full and increase their fat content as well take a longer
time to eat at meals, thus taking in more calories.
A small but significant amount of gastric bypass
patients actually go underweight because they have
experienced (as all of our patients have experienced) the
ravenous hunger after being on a diet with an out of control
appetite once the diet is broken. They are afraid of eating
again. They don't "get" that this situation is literally,
physically different and that they can control their
appetite this time by using the rules of the pouch to
eliminate hunger.
BARIATRIC MEDICINE
A much more common problem is
patients who after a year or two plateau at a level above
their goal weight and don't lose as much weight as they
want. Be careful that they are not given the "regular"
advice given to any average overweight individual. Several
small meals or skipping a meal with a liquid protein
substitute is not the way to go for gastric bypass patients.
They must follow the rules, fill themselves quickly with
hard to digest foods, water load between, increase their
exercise and the weight should come off much easier than
with regular people diets.
SUMMARY
1. The patient needs to understand how the new pouch
physically works.
2. The patient needs to be able to evaluate their use of
the tool, compare it to the ideal and see where they need to
make changes.
3. Instruct your patient in all ways (through their eyes
with visual aids, ears with lectures and emotions with
stories and feelings) not only on how but why they need to
learn to use their pouch.
The goal is for the patient to become an expert on how
to use the pouch.
EVALUATION FOR WEIGHT LOSS
FAILURE
The first thing that needs to be
ruled out in patients who regain their weight is how the
pouch is set up.
1) the staple line needs to be intact;
2) same with the outlet and;
3) the pouch is reasonably small.
1) Use thick barium to confirm the
staple line is intact. If it isn't, then the food will go
into the large stomach, from there into the intestines and
the patient will be hungry all the time.
Check for a little ulcer at the staple line. A tiny ulcer
may occur with no real opening at the line, which can be
dealt with as you would any ulcer. Sometimes, though, the
ulcer is there because of a break in the staple line. This
will cause pain for the patient after the patient has eaten
because the food rubs the little opening of the ulcer. If
there is a tiny opening at the staple line, then a
reoperation must be done to actually separate the pouch and
the stomach completely and seal each shut.
2) If the outlet is smaller than 7-8 mill, the patient
will have problems eating solid foods and will little by
little begin eating only easy-to-digest foods, which we call
"soft calorie syndrome." This causes frequent hunger and
grazing, which leads to weight regain.
3) To assess pouch volume, an upper GI doesn't work as it
is a liquid. The cottage cheese test is useful ? eating as
much cottage cheese as possible in five to 15 minutes to
find out how much foodthe pouch will hold. It shouldn't be
able to hold more than 1 ½ cups in 5 ? 15 minutes of quick
eating.
If everything is intact then there are four problems
that it may be:
1) The patient has never been taught the rules;
2) The patient is depressed;
3) The patient has a loss of peer support and eventual
forgetting of rules, or
4) The patient simply refuses to follow the rules.
1) LACK OF TEACHING
An excellent example is a female
patient who is 62 years old. She had the operation when she
was 47 years old. She had a total regain of her weight. She
stated that she had not seen her surgeon after the six week
follow up 15 years ago. She never knew of the rules of the
pouch. She had initially lost 50 lbs and then with a
commercial weight program lost another 40 lbs. After that,
she yo-yoed up and down, each time gaining a little more
back. She then developed a disease (with no connection to
bariatric surgery) which weakened her muscles, at which time
she gained all of her weight back. At the time she came to
me, she was treated for her disease, which helped her to
begin walking one mile per day. I checked her pouch with
barium and the cottage cheese test which showed the
pouch to be a small size and that there was no leakage. She
was then given the rules of the pouch. She has begun an
impressive and continuing weight loss, and is not focused on
food as she was, and feeling the best she has felt since the
first months after her operation 15 years ago.
2) DEPRESSION
Depression is a strong force for
stopping weight loss or causing weight gain. A small number
of patients, who do well at the beginning, disappear for
awhile only to return having gained a lot of weight. It
seems that they almost on purpose do exactly opposite of
everything they have learned about their pouch: they graze
during the day, drink high calorie beverages, drink with
meals and stop exercising, even though they know exercise
helps stop depression.
A 46 year-old woman, one year out of her surgery had
been doing fine when her life was turned upside down with
divorce and severe teenager behavior problems. Her weight
skyrocketed. Once she got her depression under control and
began refocusing on the rules of the pouch, added a little
exercise, the weight came off quickly.
If your patient begins weight gain due to depression,
get him/her into counseling quickly.
Encourage your patient to refocus on the pouch rules and
try to add a little exercise every day.
Reassure your patient that he/she did not ruin the pouch,
that it is still there, waiting to be used to help with
weight control. When they are ready the pouch can be used
once again to lose weight without being hungry.
3) EROSION OF THE USE OF
PRINCIPLES:
Some patients who are compliant,
who are not depressed and have intact pouches, will begin to
gain weight. These patients are struggling with their
weight, have usually stopped connecting with their support
groups, and have begun living their "new" life surrounded by
those who have not had bariatric surgery. Everything around
them encourages them to live life "normal" like their new
peers: they begin taking little sips with their meals, and
eating quick and easy-to-eat foods. The patient will not
usually call their physician's office because they KNOW what
they are doing is wrong and KNOW that they just need to get
back on track. Even if you offer "refresher courses" for
your patients on a yearly basis, they may not attend because
they KNOW what the course is going to say, they know
the rules and how they are breaking them. You need to
identify these patients and somehow get them back into your
office or back to interacting with their support group
again. Once these patients return to their support group,
and keep in contact with their WLS peers, it makes it much
easier to return to the rules of the pouch and get their
weight under control once again.
4) TRUE NON-COMPLIANCE:
The most difficult problem is a
patient who is truly non-compliant. This patient usually
leaves your care, complains that there is no 'connection'
between your staff and themselves and that they were not
given the time and attention they needed. Most of the time,
it is depression underlying the non-compliance that causes
this attitude.
A truly non-compliant patient will usually end up with
revisions and/or reversal of the surgery due to weight gain
or complications. This patient is usually quite resistant to
counseling. There is not a whole lot that can be done for
these patients as they will find a reason to be unhappy with
their situation. It is easier to identify these patients
BEFORE surgery than to help them afterwards, although I
really haven't figured out how to do that yet? Besides
having a psychological exam done before surgery, there
is no real way to find them before surgery and I usually
tend toward the side of offering patients the surgery with
education in hopes they can live a good and healthy life.
This rewrite was done exclusively for the people of this
spotlight obesity support group. It should not be sold for
any reason.
"Dummies" version rewritten by Sally Perez
Original article written by:
Mason. EE, Personal Communication, 1980.
Barber. W, Diet al, Brain Stem Response To Phasic
Gastric Distention.
Am J. Physiol 1983: 245(2): G242-8
Flanagan, L. Measurement of Functional Pouch Volume
Following the Gastric Bypass Procedure. Ob Surg 1996;
6:38-43 Rosemurgy, A.
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