How Do I Know If My Pouch Still Works?
October 14, 2016There are two types of pouch malfunctions. The first type is “loss of restriction” which is experienced as weight regain and sometimes a change in hunger. The second type is that of a pathological process that produces symptoms such as nausea, vomiting, reflux, or pain.
To understand how your pouch should work, it is best to think of it as a bathtub with a drain. If the “tub” is too big, strangely shaped or has stretched out over time it will hold too much “water” and you will have problems with satiety and hunger. You may recognize this as a loss of restriction or the sensation that you can eat anything you want. Sometimes you may not recognize any change in hunger but instead notice weight regain.
Another problem that can result in loss of restriction is a problem with the “drain”. Think of the outlet from the pouch like a drain. If the drain has stretched out over time and is too large, food will slide right through your pouch and you will again feel that loss of restriction. Conversely, if the drain is too tight or clogged from inflammation, scar tissue, or an ulcer, food won't be able to transit through (food will get caught and will not pass).
Finally, even with a totally functional pouch, if you have chronically over-eaten, the food will back up into your esophagus. After years of this, the esophagus can accommodate or become “lazy” and stretch to act as a second stomach. The good news is that if your pouch has stretched out and requires revision this can be achieved surgically and occasionally endoscopically. If your outlet (otherwise known as stoma or gastrojejunostomy) has become stretched out and is too large, this can be corrected endoscopically or occasionally surgically.
Pouch Malfunction: Loss of Restriction
As discussed above, the loss of restriction occurs in the presence of maladaptive eating habits, pouch dilation, and gastric outlet (gastrojejunostomy) dilation.
Maladaptive eating habits that result in loss of restriction can be two-fold. The first involves the over-dependence of high-calorie liquid foods and high-carbohydrate processed foods.
These develop because after bypass these foods are sometimes easier to tolerate. In fact, these foods are the very foods that shortcut the restriction which is built into the surgery to help maintain a healthy diet. You must cut these foods from your diet! They are making you sick and that is not OK. Often, seeking out the assistance of a dietitian and psychologist to break your addiction and help suggest replacement foods is helpful. Avoid high-calorie/high-carbohydrate foods such as milkshakes, sodas, meal replacement drinks, chips, and candy. Instead, focus on healthy snacks such as carrots, nuts, and protein bars/shakes (be careful with protein shakes, even this can be overdone).
The second maladaptive eating habit that may emerge after bypass is over-eating and speed-eating.
This, in turn, results in food backing up into your esophagus and over time your esophagus becomes lazy and acts as a second food reservoir or “second stomach”. To avoid this, shift your focus from eating to the point that you feel stuffed “full” to stopping when you first feel “no longer empty.” Take small bites. Meals should take no longer than 30 minutes and no liquids should be consumed 30 minutes prior to, during, or after meals to improve satiety.
If changing your eating habits provides no benefit, then further evaluation of your pouch will be necessary. Imaging the pouch with barium upper gastrointestinal series or CT can provide some information but an EGD will be necessary to fully evaluate your pouch and imaging in some circumstances may be forgone.
During the EGD your surgeon will measure your pouch and outlet as well as evaluate its mucosa for abnormalities. If it is found that the pouch or outlet are enlarged this may be corrected with an endoscopic plication procedure often performed with the Apollo Overstitch™ device. A limiting factor in the applicability of endoluminal procedures is the workspace. If your pouch is not conducive to this type of work, laparoscopic or robotic surgery may become necessary to correct these problems.
Pouch Malfunction: Pathologic Processes
Pain - Your pouch should not hurt. If you are having pain it could be a sign of a gastric ulcer, marginal ulcer, maladaptive eating habits, reflux, gastrogastric or gastroenteric fistula, or other less common pathology. If you are recently out from your surgery, it could even represent a leak and your provider should be notified immediately. If you are more than six months out from your surgery take some notes: Note the timing of the day your symptoms occur, any relation to food, or any other triggers.
If you are smoking...STOP smoking immediately, you MUST NOT be smoking, this causes ulcers to form. If your ulcer progresses, it will perforate and that will kill you! If you are a smoker, I am not beating you up. I mean this, I don't want you to die.
Treatment of ulcers can be accomplished with medications but often requires a diagnostic EGD to secure the diagnosis and surveillance EGD to ensure healing of the ulcer. I typically place a patient on a proton pump inhibitor at least 1 time daily along with Carafatete 4 times daily. I repeat a surveillance EGD in 6 weeks or more depending on the size of the ulcer and response to therapy.
Maladaptive eating habits can cause pain. In this case, pain is associated with eating and should not occur at other times. Often, liquids are tolerated but solid foods cause the symptoms. Pain that is a result of eating is caused by foods that get stuck as they pass through the stoma, high-carbohydrate loads that cause dumping, or eating too fast causing stretching of the pouch.
In order to regain control of your pouch and eating habits, it can be necessary to “hit the reset button” on your diet. You may need to go back to a clear liquid diet (CLD) for 24-48 hours, then advance your diet as tolerated. Focus on taking smaller bites, chewing well, and eating slower. Avoid stringy meats, breads, potatoes, and other foods that trigger your symptoms. If your symptoms don't improve within a few days, you need to see your provider to make sure you rule out other causes of pain.
While the above problems can often be treated with dietary modification and medications, failure to improve could indicate other serious problems. This will require a detailed discussion with your provider. If your pain is severe this could herald a bowel obstruction and medical treatment should be sought immediately.
Nausea and Vomiting
Although some nausea early after gastric surgery is common, vomiting is never normal. Pay close attention to the nature of your vomiting including the timing (surrounding events), amount, color, taste, smell, frequency, triggers, and duration. Notify your provider immediately if you have any vomiting early after surgery. The cause of early vomiting is often related to medication side effect or attempts at advancing your diet too fast, but can be an ominous sign of leak and infection and needs early evaluation.
After the initial adjustment period to your pouch, nausea or vomiting can be a sign of gastric outlet (gastrojejunostomy) stricture, gastric and enteric ulcer, maladaptive eating habits, gastrogastric or gastroenteric fistula, intra-abdominal abscess, or partial or complete small bowel obstruction.
If your nausea is caused by stricture at the gastrojejunostomy site, a diagnosis will need to be made by EGD. For the majority of time, this can be treated with an endoscopic balloon dilation without further surgery. 90% of patients will be improved with a single dilation and 95% will improve with two. Rarely a patient will require more dilations prior to completely relieving the symptoms. During these treatments, you will require anti-acid medication and dietary restriction including a liquid diet. Adjunct therapy to dilation can include placing stents. Rarely surgery is required.
The bottom line is that pouch malfunction may occur for a number of overlapping reasons. The clues that suggest the underlying pathology are subtle and not always clear. To secure a diagnosis EGD is often required. Vomiting and pain are never normal. Ignoring these symptoms could put you at serious risk, even progression to death. If you are having symptoms to suggest a problem with your pouch or are simply experiencing weight regain, see your provider, they can probably help.
 | ABOUT THE AUTHOR Dr. Steven Udelhofen is a member of the American Society for Metabolic and Bariatric Surgery, American Osteopathic Association, American College of Osteopathic surgeons. He is a Bariatric surgeon at Journeylite of Cincinnati. He also has had several local and national speaking engagements and presentations including poster presentation at the ASMBS National Obesity Week 2016. |
