Taking Care of your Gastric Pouch

Can you stretch our your pouch?

Every bariatric surgery patient is sincerely motivated to take good care of their new little stomach pouch.  They’ve heard stories about someone who ruptured their pouch, or someone else who “stretched the pouch” and “gained all their weight back.”  Patients invest massive time, money, and emotional energy in their bariatric operation so they want to do everything possible to succeed.  This concern is common for both Gastric Bypass and for Sleeve patients. 

The good news is that while it’s possible, it’s actually pretty hard to damage the gastric pouch by rupture or by serious stretching. We’re going to break these risks down into concerns about causing rupture or leak in the first month after surgery, versus the long-term idea of stuffing with so much food, so often, that one re-expands the tiny stomach back to something like the normal size.

We’re aware of cases where each of these has happened, but they are exceedingly rare. To be on the safe side, we’ll talk about how to avoid these problems. Then we’ll take it a step further and discuss how to train your little stomach pouch to work well for you over many years.

As we discuss the potential for pouch damage, we’re really talking about food leading to excess pressure. Thin hydration fluids should not cause damage. As far as we understand, it’s impossible to damage the gastric pouch with thin hydration fluids because it is easy for the fluids to move downstream or back up (regurgitation, throwing up). We believe that thin fluids alone should not be able to build up enough pressure to cause rupture or leak, though it certainly feels better to take frequent small sips rather than big gulps of fluid.

Check our YouTube on the safety of fluids https://youtu.be/gfAu3CDmzpc

Early phase – rupture/leak

In the first month after surgery, your new gastric pouch will feel very small and “stiff,” meaning that it can go from an empty feeling to “super full” in just one bite. This stiffness comes from the natural swelling and the healing process that your stomach must go through to recover from our stapling and suturing. During this recovery phase, the stomach pouch is less effective in moving food downstream. The natural stiffness and slowed emptying mean that one can potentially build up a lot of pressure by swallowing too much food, by swallowing food too fast, or by not chewing thoroughly.

In fact, many patients have accidentally eaten enough to cause pressure and pain. This is not ideal, but almost always, they can get past the pressure sensation with time or sometimes by throwing up. Throwing up or dry heaving can feel pretty traumatic, but we have never seen the pouch rupture from eating “one bite too many” once or twice during the early learning phase.

As long as one learns from these episodes and goes forward with smaller/slower eating, there is no harm done.  The rare occasions in which excess food has caused pouch rupture have been situations where the patient forced full-sized meals of regular solid food into their small stomach pouch during the first couple of weeks after surgery, overriding the feelings of fullness, pain, and nausea. In other words, don’t eat a full cheeseburger a week after surgery.

Of course, the best plan is to be conscious of your small/sensitive gastric pouch and treat it gently. Many patients re-learn how to eat smaller amounts and how to be satisfied without ever feeling pain/pressure/nausea. This “conscious eating” is the best way to have a smooth recovery and the best-lasting weight loss.

Late phase – pouch stretching and weight regain

The first thing to understand is that every bariatric gastric pouch naturally becomes more “accepting” of food and gains food capacity over the first 6 months or so after surgery. Normal stomach tissue is quite stretchy and flexible, like a kid’s balloon. Expected surgical trauma causes the stretchy stomach tissue to be stiff and much less flexible, something more like an old-fashioned hot water bottle that grandma used for her back pain. It takes several months after surgery for the tiny new stomach pouch to resolve its inflammation and gradually return to its natural stretchy condition.

It’s very common for patients at 6 months to “suddenly” feel like they can hold a lot more food. Even after this transition to “larger capacity,” our patients always feel full/satisfied with far smaller volumes of food than before their surgery. The transition to larger food capacity is natural and expected – see our YouTube for more information about the natural evolution of pouch size: https://youtu.be/vhi-WM1MnKc.

Another important fact is that the “lesser curve” part of the stomach that we use to form the small gastric pouch for the gastric bypass or the gastric sleeve is the least stretchy part of the stomach. When we re-test our patients’ gastric pouch years later using X-ray testing or endoscopy, we typically find that it remains small and nicely formed. It’s just that the natural stretchiness allows it to comfortably hold a small regular meal, then shrink back down once the food passes. Just like a kid’s balloon.

On the other hand, we have seen a few patients with an eating compulsion who stuff with food to the point of pain/nausea several times per week, if not per day. Over months and years, this repeated pressure on the small stomach pouch can cause it to expand, but these observations are instructive since they show us how much effort it takes to physically stretch the surgical gastric pouch out of shape.

Although it’s fairly hard to damage your small gastric pouch, it’s quite common to accidentally “train” the gastric pouch to accept fairly large volumes of food, and (obviously) we’d really rather not do that. We’ll wind up with some “best practices” so that your new little gastric pouch still feels small for years to come.

Best practice: Nurturing your gastric pouch and keeping it “in shape”

As mentioned briefly above, many patients unconsciously “train” their gastric pouch to handle large volumes of food. The bad news is that it’s possible to do this; the good news is that a proactive patient can avoid the habit of large-volume food or, if you’re already in the large-volume habit, you can gently re-train your stomach pouch to a smaller “satisfaction capacity.”

Tips for eating in a way that is satisfying, while eating only a small amount of food:

• Be conscious and attentive with all your food-related activities, including selecting the food, preparing the food, and the actual eating process outlined next. Try not to multi-task with your eating (TV, phone, work, reading, etc.). If you don’t have time to focus on eating as your sole task, then wait until you have time.
• Choose not to eat until you feel hungry. If you follow this instruction faithfully, you will probably only eat twice per day, sometimes only once. Trust your body to let you know when it needs nutrition. Intentional fasting is a good plan; check our blog here:
  https://www.sagebariatric.com/intermittent-fasting/. Also, look for our upcoming blog about not being afraid to be hungry for a little while.
• Choose low-carb food that is solid, like seafood or beef or chicken, or salad. Soups and mushy foods will flow out from your stomach pouch fairly quickly, so they will give you less lasting sense of fullness.
• Before you take your first bite, do some brisk intentional hydration with water or another simple 0-calorie fluid. Not only will hydration help your metabolism work better, but the gentle “pre-stretch” of your stomach pouch that you get from brisk water intake will take the edge off your hunger and will help you to eat more slowly, more consciously.
• Once you take your first bite of food, no more drinking. Remember, soupy food will flow down and out of your stomach pouch. Equally important, the process of chewing and swallowing without drinking takes a bit more time and effort. This means more time to enjoy the texture and taste of your food, and also more time to notice when your hunger fades away. Once you have finished eating, wait 1 hour before drinking again.
• Try to make your small meal last at least 20 minutes. The nerves that sense the transition from “hungry” to “satisfied” are kind of slow, so it’s helpful to give them time to tell your brain that you’ve had enough.
•  When your hunger is gone, before you feel full, stop eating. If there is food left over, so be it. This last point will only work if you are conscious of what you are doing and if you choose to use hunger as your signal for eating. This process of conscious eating should help you be satisfied with small normal meals, and it can often “re-set” a large capacity gastric pouch down to a smaller size.

We hope this is helpful on your journey!