Re: Another case in point: Pouch Rules For Dummies (long)

[Guest guest]

Great article, . I never knew how wonderful the RNY really is. It

made me see just how small minded I can be. Now that I know the truth, I

can be just as " nice " and tolerant as Jean.

Best -

Nick

Another case in point: Pouch Rules For Dummies

(long)

> Anyone who is considering the RNY should first read this essay written

> by an RNY surgeon. Very eye-opening. (Cites at end of article.)

>

>

>

>

> -----------------

>

> 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 and 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.

> 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.

> 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.

> To assess pouch volume, an upper GI doesn't work as it is a liquid.

> The cottage cheese test is useful and eating as much cottage cheese

> as possible in five to 15 minutes to find out how much food the 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.

>

>

> 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.

>

> 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.

>

> 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.

>

> 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 exclusivly for the people of this spotlight

> obesity support group. It should not be sold for any reason.

> " Dummies " version rewritten by Sally

> Original article written by: Mason. EE, Personal Communication, 1980.

> Barber. W, Diet al, Brain Stem Respons 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.

>

>

> ----------------------------------------------------------------------

>

[Guest guest]

--

Thanks for that report--OMG, if I had seen that before I found the DS

as an alternative I would have stayed fat and never ever looked at

weightloss surgery again!! I had just done a cursory looksee at WLS

a couple of times in the past and had hesitated. But when my health

had declined I got depsparate. This report would have scared the

s*** out of me!!

Talk about being chained to a diet---yikes no wonder they have so

much regain going on!! If they lose the dumping afect--they are

sunk. I am so thankful for the liberation of the DS!! Thanks to

everyone who has put their stories out there for all to see--and make

an intelectually honest decision.

Pammi

-35#'s

10/15/01

Spain