Editors Note: This is the first of what I hope to be many entries I add that were originally written by Ian, AKA baka. Ian is an RNY post-op that is very active on the BariatricTV forums and someone I met and hung out with in Vegas back in February. He’s agreed to let me put these various tid-bits written by him up here on FFD. Ian is NOT a medical professional, but he is a very dedicated patient that spends a lot of is own time doing a lot of research and helping others when questions related to WLS pop up.
This particular topic came up when someone asked a question about how much they are eating, how much they should be able to, and if they could stretch out their pouch.
Stretching My Freaky Pouch
We get Freakified by having RNY our stomachs capacity reduced by well over 90%. A normal stomach can stretch, sometimes to over 1000 ml (40 to 50 ounces and is roughly the size of a person’s head), while the freaks pouch will be about 15 ml in size (1 to 2 ounces) – It’s about the size of your thumb.
The Freaky pouch is usually formed from the part of the stomach at the bottom of the esophagus which is least susceptible to stretching.
Freaky Mechanics
When the patient ingests just a small amount of food, the first response is a stretching of the wall of the stomach pouch, stimulating nerves which tell the brain that the stomach is full. The patient feels a sensation of fullness, as if they had just eaten a large meal—but with just a thumbful of food. Most people do not stop eating simply in response to a feeling of fullness, but the patient rapidly learns that subsequent bites must be eaten very slowly and carefully, to avoid increasing discomfort, or even vomiting.
Food is first churned in the stomach before passing into the small bowel. When the lumen of the small bowel comes into contact with nutrients a number of hormones are released including cholecystikin (CCK) from the duodenum and PYY and GLP-1 from the ileum. These hormones inhibit further food intake and have thus been dubbed satiety factors. Ghrelin, is a hormone that is released in the stomach that stimulates hunger and food intake. Changes in circulating hormone levels after being Freakified have been hypothesized to produce reductions in food intake and thus body weight. However, these findings remain controversial.
The Freakfied Digestive Process
About 40% of the digestive enzymes required to fully break down simple starch-based carbohydrates is contained in our saliva (known as ptyalin). To break down complex carbohydrates, protein and fat, our body requires the addition of gastric acid and other digestive enzymes normally produced in the stomach. But our new Freaky pouch does not produce in any significant amount of gastric acid or enzymes. This is one of the main reasons why we need to chew, chew, chew really well.
Once food gets to the pouch, the digestive enzymes from our saliva and the limited amount produced by the stomach go to work on the food to begin breaking it down. Our pouch doesn’t churn as much as our old stomach used to, but there is still some movement with that well-chewed food.
The longer food stays in the pouch, the more it is broken down and prepared for the intestines to do their work of grabbing micro and macro-nutrients from the food. If we wash the food out too quickly a few different things happen. First, if food is not properly prepared for optimal absorption (chewed well, mixed with enzymes) we risk having food move too quickly through our digestive track without the benefit of full nutrient absorption.
Second, if food is not well chewed or broken down, we are also at greater risk for intestinal blockages or constipation.
The Other Big Risk
There’s also the risk of stretching the stoma (the opening between the pouch and intestines). If you have dense food that has not yet begun to be digested in the pouch and you drink fluid you are forcing dense food through the stoma prematurely. The opening is only about the size of a lady’s index finger, but if you habitually push food through the opening before its ready to go, you’ll eventually stretch the stoma. This is far more worrisome than stretching your pouch. Once the stoma is stretched it can become the same diameter as the pouch itself. This would essentially create one big long tube that food can be packed into at meals. Need a visual? Stretching your stoma would give you a 20-foot long stomach.
This caution from surgeons is not a scare tactic. This rule is about biology and medical science because now you have to manually do the work of the pyloric valve that has been bypassed. By following this rule for the rest of your life, you’ll properly prepare your food to give your body the best chance of absorbing the vital nutrients it needs for survival as well as achieve the level of satiety needed to reduce hunger between meals.
How big will my Pouch Get?
A Surgeon did a study over ten years, He 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 him an idea of the size of their pouch at three month intervals. He 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.
He 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.
How Much Food Should I Be Consuming?
You want to eat until you are satisfied. 1-1½ cups is pretty much the amount that most postops will eat when they are further out but some of that will depend on what you are eating (Salad vs. Dense Protein etc). Generally speaking regular meals larger than 1½ cups will result in eventual weight gain.
It is common to get to your goal and experience a bounce-back regain of 10% of your excess weight. The great news is that you can always lose the weight you gain.
It will be more difficult the second time around to lose weight because your malabsorption rate is at the highest it ever will be immediately after having your surgery. That is why you lose so quickly and easily the first year or so after getting Freakified.
Remember
As we know to gain the maximum benefit from our surgery, it is important that we eat only at mealtimes and avoid snacks/grazing between meals, which can effectively “bypass the bypass”.
This requires a major change in eating behavior, and alteration of long-acquired habits. The cause of regaining weight in the majority of cases is eating between meals, usually high-caloric snack foods and forcing food through the stoma prematurely by consuming fluids too soon after eating – Stick to the 30/30 rule!.
There is no known operation/procedure which can completely counteract the adverse effects of destructive eating/drinking behaviors.
Ian
Great info. My surgery is next week, and I’m reading all I can to be prepared!