Understanding Your Pouch
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
