"Is my Pouch Too Big?"

“I’m able to eat a lot more than I think I should!” “Is my pouch Too Big?” -or- “Have I stretched My Pouch?” Very Common concern and question from those with an RNY. (saw bman’s question, and thought I’d “Re-Post.”) As always- skip if you’ve seen it……. --------------------------------------------------------

There’s some conflicting info out there about- “Stretching the Pouch” – And - “Stretching the Stoma.” A lot of it is complete ‘urban legend’ Aimed at explaining why one procedure is ‘better’ than another. Typically this information is passed on from someone Who did not have the procedure they are ‘slamming,’ and know little other than-  “What I’ve heard is….” That’s where all of that crap like--  “Most people gain it back…”  “RNY’ers can Never chew gum, eat red meat, or take pills again…” And such come from. There are the rare exceptions where “A Lemon” of a surgery Causes Staple-line disruption and that is a serious problem. I know of 2 folks who had that exact problem. However, both had a revision of their surgery and are losing now. I’m in no way an expert at all. I did have A LOT of extra time on my hands Early on due to complications to do nothing but research and even directly e-mail Different Bariatric Clinics/Doctors and take part in a lot of On-Line chats with Bariatric Surgeons. Many do these, and they are very valuable. They even post the transcripts for those who missed recent chats such as-- http://www.communitymemorial.com/chat/bariatric_chat.cfm or- http://doctorsimpson.com/chattranscripts.php Many are accessible and the Surgeons are great about answering questions To those who sign up for their newsletters and such.  Like- http://www.lapsf.com/office-information.php Having 9 months of “down time” to ask questions, Got a lot of answers. So, The “Stretching” question? ------------ Equally reputable Docs have stated different opinions on it. Dr. D. Rodriguez, founder of the Texas Bariatric Center , since 1998 Says-  “It is expected and appropriate that the stomach pouch will enlarge somewhat As the months pass after gastric bypass.  Some of this enlargement Is an actual increase in size, and some represents a softening  (regaining of elasticity) of the pouch and its outlet.” Similarly, Dr. Latham Flanagan, MD –  (website is at The Oregon Center for Bariatric Surgery) Indicates that the average size of the mature pouch is 5.5 ounces. He also states that –  “…sizes ranging from 3 to 9 ounces have NO IMPACT On the person's success in weight loss.  The pouch actually grows Rather than stretching as most think.  For most of the patients that have the surgery, The pouch stops growing at about 6 oz and the largest is about 9 oz.” Compare this to normal stomach sizes between 24 to 64 ounces. Flanagan was the one who presented the “Cottage Cheese Test” To the June 2000 meeting of The American Society for Bariatric Surgery. (ASBS) Although he had been using it for quite some time. Although- Albert Wetter, M.D., of the Mills-Peninsula's Bariatric Surgery Program, Among the first to participate in the American Society of Bariatric Surgeons’  “ Center of Excellence designation process,” presents the pouch as “Stretchable.”- According to Wetter-  “It is very important that you protect your stomach pouch by not overeating Or drinking too much fluid at one time. It's normal for the pouch to stretch somewhat over time, but frequent stretching will increase stomach capacity and lead to weight gain.  This defeats the purpose of gastric bypass surgery.” Faced with conflicting info from reputable sources, I asked my Doc- “What’s Up?” He’s also part of a ‘flagship’ program and designated a “ Center of Excellence .” His response?  “…Not every patient is a University Professor digging for the studies To back up every detail. So, it’s easier for some Surgeons to just say- Don’t do ANYTHING that will defeat your success!  Sometimes that’s easier and it’s more effective that loading them down with a bunch of statistical data. If a Surgeon has a patient or two who have to go to the hospital to have gum removed From their Stomas, he’ll begin telling all of his patients- Don’t Chew Gum! Rather than tell them not to swallow their gum or – …be careful because I’ve seen a few cases where patients have had this problem.” So, “Stretching the Pouch” – And - “Stretching the Stoma.” The answer isn’t so much do they stretch or even what size are they. The Real answer is that the FUNCTIONAL size varies with many factors. Such as- Time of day, The amount of time taken to eat, And (most importantly) the type of food eaten. It is expected and appropriate that the pouch will handle A much smaller amount of solid food (i.e. chicken) than mushy or liquid stuff like soup. The “Cottage Cheese Test?” It is meant to be a standardized, reproducible measurement Of the physical size of the stomach pouch in a person Who has undergone a gastric bypass procedure. If you are curious about your Pouch size, here it is------- Purchase a container of small curd low-fat cottage cheese. Begin the test with a full container, And perform the test in the morning before eating anything else  (this will be your breakfast on that day). Eat fairly quickly until you feel full (less than five minutes). Note that the small soft curds do not require much chewing. The idea with the rapid eating is to fill the pouch Before there is much time for food to flow out of it. After eating your "fill" of cottage cheese,  (just to first feeling of full, not to pain.) You will be left with a partially eaten container that has empty space Where cottage cheese used to be. You can measure the remaining amount and calculate the amount. Dr. Flanagan’s Protocol suggested-  “Start with a measured amount of water (16 ounces, for example), And pour water into the partially empty container of cottage cheese Until the water is level with the original top level of the product.” Obviously, the amount of water poured into the container, Equals the functional size of the pouch. You will probably find that the "cottage cheese" size of your pouch Is bigger than your surgeon told you he/she made it at the time of surgery. But “worry about this causing problem with weight loss?” Remember the statistics- 17% of RNY patients reach their Ideal Body Weight. 68 % of RNY Patients Lose between 75% to 99% of their excess body weight. *(That’s approx. 85% of All RNY patients Reaching a BMI close to or within the NORMAL RANGE!) 10% or 10 in 100 lose an average of 63% of their excess body weight. *(most of these will be Overweight like the rest of the non-Morbidly Obese People in the country) 5% or 5 in 100 RNY patients lose less than half of their excess body weight. Odds for Diet & Exercise alone? 9 out of 10 will gain back all of their lost weight, Many, gaining to higher BMI than they had when starting a diet program. Further, Most Bariatric Surgeons state that –  “…it is not the pouch size that causes people to regain weight, but that they never learn how to use their pouch properly.  The pouch is misused by grazing throughout the day, drinking hi-calorie liquids, or eating soft easily digestible foods that are high in carbohydrate and fat, such as fried potatoes, sweets, breads, and pasta.” Worried that “this weight loss tool will stop working and I will resort back to my old self.” Very Common Worry.  As common out here as Deep Navels! 5 out of a Hundred may have that problem.  But not due to it becoming “Stretched Out.” Yes? Continue using this first year to Re-Learn new eating habits And Food choices, and later on down the line, It will be easier to just Keep doing what you’ve gotten in the habit of doing. That’s a pretty effective tool.   “Keep doing something Habitually….” It’s how most of us got Obese to start with.  Yes? Forgive my long-winded ramble as an answer. I just prefer more info than the simple-  “Don’t Do ANYTHING that will Defeat your Success!” One last bit---- “The pouch” is made from the upper most portion of the stomach The extreme Proximal / Lesser Curvature portion Comprised of the ‘Cardia’ and a portion of the ‘Fundus.’ Which is the least “Stretchy” and more muscular of the stomach tissue. Hope this helps- Best Wishes- Dx

Very good info Dex!  There are times when I feel like my pouch must be 2 cups large to hold what I've just eaten, and there are other times when certain foods(or days) I can only eat tiny bits. I have no idea why it's like this, but the whole thing's still a mystery to me anyhow.

If it's "juicy" like tomatoes and squash? I can eat a lot. If it's dense chicken breast? I'm full on much less. For me it's all about the water content. And also "stuff that swells" in water Will fill me up quickly too. Pasta?  Just about 1/2 a cup.... And soon it feels like 2 cups. I'm pretty good at estimating just bt looking now Which foods will fill me up With 1 cup, and which ones can take nearly two. Best Wishes- Dx

Very true Dex!  It seems as though the dry dense meats like chicken breast or lean pork do not sit very well and I have to stop after only a few bites or I don't feel good.

Thanks Dx....my own appetite size seems very much like your own! Great reading once again too! Jim