Understanding
the function of the small gastric pouch
After surgery,
it will be your responsibility for the lifestyle changes necessary
to make the small gastric pouch function properly. It is thought
that the pouch walls stretch with the eating of a small meal,
or even the drinking of fluid. The meal volume will increase
over the months. Stabilization occurs at two years, with a mean
pouch size of six ounces, with a wide range of three to ten ounces.
The pouch appears to not get larger after the second year. Success
in weight loss and maintenance depends not only on having a small
gastric pouch but even more so on how the patient makes the required
lifestyle changes, uses their "pouch/tool". and adequately exercises.
The accomplishment
of satiety or suppression of hunger,
is fundamental to the success or failure of bariatric operations.
Almost all patients have a profound satiety, 24 hours per day,
in the first six months following surgery. Patients achieve fifteen
to twenty-five minutes of satiety after rapidly drinking water
to a point of fullness. They do not redevelop a normal appetite
preceding the next meal until 6 to 12 months post-op. Some patients
fail their surgeries by staying too long on liquids or soft solids,
the "soft calorie syndrome". They fail by becoming hungry too
soon before their next meal, and giving in to snacking between
meals because of their hunger. High calorie drinks have the ability
to defeat weight loss or maintenance.
The return
of appetite occurs about six months. At this time, the average
pouch size is four ounces. The patient can ordinarily drink six
to eight ounces of water at a time.
The Ideal
Meal Process
The ideal
meal process is described as getting through the day without
hunger on three meals a day. There needs to be about five hours
between meals. The optimum meal is a more solid type of food,
such as finely cut meat and minimally cooked or raw vegetables.
The meal should be taken over five to fifteen minutes, depending
upon the functional pouch volume. Stringing a meal out over 30
to 45 minutes is one technique used to "beat the pouch". After
1-1/2 to 2 hours following a meal, begin drinking low or no-calorie
fluids up to 15 minutes before the next meal. This use of fluids
can substitute for taking in unwanted calories through snacking.
Finetuning
of the pouch/tool is probably not accomplished until the patient
redevelops hunger before the next meal, in the sixth to twelfth
month after surgery. Techniques on delaying the return of hunger
are not relevant when they are not hungry, as in the first
six months.
Vomiting should
be prevented if at all possible. For the first few months,
a patient's mouth will be larger than his stomach. The
most common cause of vomiting is overloading the stomach. We
encourage patients to continue to measure their meals. There
are more complexities when eating foods such as rice, pasta and
granola—foods that swell in the stomach after being eaten
because they are incompletely rehydrated before being consumed.
Three Principles
for Gaining and Maintaining Satiety
| 1. |
The
pouch needs to be filled with adequate wall distention with
each meal. |
| 2. |
Slow
down the emptying time (by eating solid foods and avoiding
liquids fifteen minutes before and 1-1/2 hours after eating). |
| 3. |
Adequate
protein with each meal. Emphasize three meals a day. Breakfast
should be eaten 1-2 hours after arising. High calorie fluids
should be avoided. |
The golden
opportunity for maximizing weight loss is the first six months
after surgery. Two-thirds of the pouch growth occurs in the first
six months. Every day the patient should take advantage of their
present opportunity and get as active as they can.
Honeymoon
Syndrome
The satiety
and rapid weight loss due to intake restriction can lead patients
to believe that circumstances will never change. This is the
honeymoon period. Weight loss will slow. You may experience a
false sense of comfort. Food selection, liquid calorie control
and exercise are important.
Exercise
Exercise is
critical for a healthy lifestyle. Exercise is necessary to maintain
weight loss in the overweight person. The release of endorphins
with aerobic exercise improves emotional stability and mental
clarity. Endorphins, adrenalin, norepinephrine, etc., also act
in an antidepressive manner. In the first six months,
regular aerobic exercise improves basal metabolic rate that
is observed to drop during rapid weight loss.
Long-Term
Weight Management
| 1. |
It
is important to take solid food rather than liquid food to
maintain satiety. |
| 2. |
Avoid
liquids with meals to prevent more rapid emptying of the
pouch and shortened period of satiety. |
| 3. |
Support
groups offer feedback for individuals and provide reinforcement
of the principles of pouch use. |
Teeter-Totter
Effect
On one end
is the exercise/phyiscal activities. On the other end is the
meal choice discipline and fluid restrictions.
| 1. |
When
one has a large amount of exercise, the amount of effort
placed on diet lightens up. |
| 2. |
When
one is light on activity, one has to be heavier on the diet
discipline side. |
| 3. |
If one
is light on both exercise and diet, weight is gained. |
| 4. |
If one is heavy on both exercise and diet, weight is lost. |
Too Much Weight Loss
Up to 15% of patients can lose too much weight in the first and
second year post-op. We encourage them to taper off their efforts
with diet discipline by adding some fat back to their meals and
eating and fourth or fifth meal a day with less discipline on the
fluid management.
Depression
Depression is a powerful inhibiter of success after surgery. Patients
have reversed the learned principles of the use of their pouch/tool:
grazing and snacking through the day, drinking high calorie liquids,
drinking liquids with meals, and stopping their exercise. Consider
professional counseling, as needed and continue to use your pouch/tool
as best you can. Consider a "refresher" course" in the use of the
principles of the pouch/tool at some time in the future.
Adapted from: Understanding the Function of the Small Gastric
Pouch: Application to Post-op Teaching and Evaluation, by Latham
Flanagan, Jr., M.D., FACS
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