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

[Guest guest]

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

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

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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 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.