Re: Drinking/thirsty

[Guest guest]

wow did this ever click --- i understand so much more how it works now and

found i am going to change a few things -- i do ok on the eating , exercise

,.but need to work on the drinking more part and spacing -- guess that is

why i can eat crackers and junk like that so easy -- needs to be replaced

with either nothing or water thanks for whom-ever did this homework for

us --thousand times over -- just to let you know i will even go the extra

and keep a log and let you all know how much a difference the outcome

di ---going to be a month study starting july 18 thru aug 18

Drinking/thirsty

>

>

> Here is an article that might shed some light on the drinking etc. with

meals along with some other information. Now although it was not written by

our beloved Dr. R, (Dr. R feel free to chime in, maybe he even knows the Dr.

that wrote this,) there is some information I have found useful.

>

> POST-OP TEACHING AND EVALUATION

>

> By Latham Flanagan, Jr., M.D., FACS

>

> Article is sectioned by capitalized categories.

>

> INTRODUCTION

>

> >From our earliest experiences in bariatric surgery, we have been

> intrigued with the question " How does our operation cause weight loss

> and maintenance? " As we talked to the public, and even our medical

> peers, it became evident that a common concept of the uninformed is

> that the small gastric pouch simply mechanically restricts intake,

> preventing the post-op patient from eating too much. Indeed,

> superficially, it may appear that way especially in the first 3-9

> months post-op. However, even a short experience with following our

> patients shows us that with a meal size of even three to five ounces,

> certain patients will stop losing weight and start to regain. We also

> note that two to five or more years postoperatively certain patients

> seem to have a large meal volume of six to ten ounces but still

> maintain good weight control without an noxious degree of hunger. It

> has become clear with experience that the principle of weight control

> is the achievement of satiety, or the absence of abnormal hunger,

> associated with the ingestion of the appropriate number of calories

> sufficient to meet the person's need. If adequate satiety is

> achieved, our patients are successful. . . And they fail if that

> satiety is not achieved. When patients " fail " there is a tendency,

> even among bariatric surgeons, to pass it off as " noncompliance. "

> Certainly, this can be an appropriate evaluation in a few persons who

> are not willing to accept responsibility for the lifestyle changes

> necessary to make the small gastric pouch function properly. But, is

> this the problem for the majority? I think not. When failure does

> occur, it is usually the inability to maintain the post meal satiety

> long enough to prevent snacking before the next meal time arrives.

> Also, it could be due to ingestion of a large number of calories in a

> form that is somewhat hidden to the patient and is not responsive to

> the gastric pouch restriction, especially high calorie liquids.

>

> HYPOTHESES OF POUCH FUNCTION:

>

> At this point in time what have we learned about how the small

> gastric pouch works? In the form of an hypothesis, we can now state

> that the basic mechanism is that of stretch of the pouch walls with

> eating of a small meal, or even the drinking of fluid. This stretch

> is sensed by the stretch receptors in the pouch wall and relayed by

> neural pathways to the appetite centers in the hypothalamus by way of

> the tractus and nucleus solitarius. The second hypothesis is that

> successful maintenance of satiety depends upon the creation and

> maintenance of a small gastric pouch and a small gastric pouch outlet

> (Mason- reference 1). The third hypothesis is that the observed

> increase in functional meal volume over the months and years

> following a gastric bypass procedure is due to the process of

> hyperplasia and is not wholly or in great part due to noncompliance

> on the part of the patient. The fourth hypothesis is that

> understanding of these principles and effective teaching to a

> compliant patient results in better weight loss and maintenance than

> if the teaching is not accomplished.

>

> PUBLISHED DATA

>

> To support these four hypotheses, we have two pieces of reasonably

> good scientific information from peer reviewed published articles.

> From that point we must rely on observational-based science.

>

> Our first question is how does the small gastric pouch create

> satiety? Considerable insight on the neurological pathways of satiety

> has been obtained through the work of Barber, a Ph.D.

> veterinarian, and his associates who published a paper in 1983

> entitled " Brain Stem Response to Phasic Gastric Distention. "

> (reference 2) They placed a balloon in the stomachs of anesthetized

> cats and surrounded the stomach with a strain gauge. Microelectrodes

> were placed in the nucleus and tractus solitarius of the brain stem.

> They found a population of neurons that faithfully monitor moment to

> moment changes in gastric wall tension. The discharge frequency to

> wall tension did not adapt for the twelve hour period of the

> experiment. This response was dependent upon an intact vagal nerve in

> these cats. They concluded that " these neurons may serve as a

> critical link between the stomach and higher centers in the conscious

> perceptions of fullness. " It seems particularly impressive and

> interesting that the neurons continued to fire at an accelerated rate

> for as long as twelve hours, if the gastric wall tension remained

> high.

>

> Another question of considerable importance to the thinking of a

> bariatric surgeon is what is the fate of the small gastric pouch?

> Does it enlarge at all after the surgical procedure? If it does

> enlarge, is it because the operation was done improperly? Was it

> because of gross patient noncompliance and gorging? Or, is it due to

> the kind of hyperplasia seen throughout the gastrointestinal tract, a

> response to loss of function? Dr. E. E. Mason, at one of the Iowa

> Bariatric Symposia in the early 1980's, suggested that it might be

> useful to ask patients to eat cottage cheese in a structured manner

> in order to attempt to determine their functional meal volume at

> different times postoperatively. I took the idea home and began

> asking all of my patients to do this simple test with each one of

> their follow-up postoperative visits at three, six, nine, twelve,

> eighteen, and twenty-four months. We continued to do this over the

> next decade (and subsequently to date), and figure 1 reveals a

> regular, progressive, stepwise increase in functional pouch volume

> over time that strongly suggests the orderly process of hyperplasia.

> Stabilization occurred at two years at a mean pouch size of six

> ounces with a wide range of three to nine-ten ounces. The pouch

> appears to not get larger after the second year. (reference 3) These

> gastric bypass pouches were created as a vertically oriented, 30 cc

> pouch measured against both volume and pressure of 70 to 85 cm of

> water. The curve of pouch enlargement is the inverse of the weight

> loss curve.

>

> We then proceeded to compare the patients' weight losses at one and

> three years to pouch sizes at one year. Figure two reveals that there

> was no difference in percent excess weight loss at one year, with the

> different pouch sizes within this range of up to nine-ten ounces. We

> then compared the largest third of pouch sizes to the smallest third

> of pouch sizes, and still there was no significant difference in

> weight loss at one year or of maintenance at three years. This

> finding is, perhaps, the most important result to come from the

> Cottage Cheese Test work. It strongly suggests that within these

> limits of pouch sizes that success in weight loss and maintenance

> depends not only on having a small gastric pouch but even more so in

> how the patient uses their " pouch/tool. " If this is true, then the

> implication is clear that learning how to use the pouch/tool

> effectively is important and that it is our responsibility as

> bariatric surgeons to see that effective teaching is made available

> to our patients over this two year period of changing intake and

> satiety control. In brief, the Cottage Cheese Test data tells us that

> within the context of a small meal volume, lifestyle change including

> exercise is the most important variable. The stepwise progressive

> growth in the functional pouch volume (meal size) probably defines

> the rate of weight loss for the patients taken as a whole, but the

> degree of weight loss and maintenance for the individual patient is

> more dependent upon that patient's ability to make the required

> lifestyle changes: proper use of the pouch/tool and adequate amounts

> of activity and exercise.

>

> OBSERVATIONAL-BASED MEDICINE

>

> Observational-based medicine has a long history of respect going back

> to the early work of two of my personal surgical heros, s

> Vesalius and Ambrose Paré. Indeed, we often refer to the " art and

> craft of surgery " . Although we do make great effort to have a

> scientific basis to our surgical decision making, ideally with

> prospective randomized studies or double blinded studies, at this

> point in time the majority of what we do is based on empiricism, or

> observational-based medicine. The observations that I would now like

> to share from my own personal thirty-three years of experience in

> bariatric surgery are also shared by many other experienced bariatric

> surgeons of my acquaintance, although not all would agree with all of

> these principles.

>

> For the first fifteen years, although I remained busy in a general

> surgical practice, my primary interest, bariatric surgery, lagged

> because of the lack of patient material, primarily because of the

> profound discrimination of medical insurers against the morbidly

> obese in our area of the country. What appeared to be a disadvantage

> initially became an advantage, as I thereby had the opportunity to

> follow almost all of my patients personally during that time. As

> there was little known about the mechanism of action of the gastric

> bypass procedure, I spent a good deal of my time thinking about

> possible mechanisms and observing the differences between patients

> with good weight loss and those with poor weight loss. Since the

> beginning, I have performed the short limb gastric bypass procedure

> (GBP), only adding the malabsorption procedure of the banded

> gastroplasty/distal gastric bypass procedure (BG/DGB) in 1992. The

> BG/DGB also uses a small, vertically oriented gastric pouch quite

> similar to the gastric bypass procedure pouch, the difference being

> that the outlet is controlled by a band as in the vertical banded

> gastroplasty and silicone ring gastroplasty, etc., instead of a

> gastroenteric anastomosis. My observations seemed to be similar for

> the two procedures, although not identical for both. The Cottage

> Cheese Test was done only with the GBP. Considering the above, what

> do I think that I have learned?

>

> The following are observations that may have an effect on the

> function of the gastric bypass pouch:

>

> 1. We have come to understand that the accomplishment of satiety, or

> suppression of hunger, is fundamental to the success or failure of

> bariatric operations.

> 2. We have come to understand that success relates anatomically to

> creating a small pouch that remains relatively small and a small

> outlet that remains relatively small (Mason).

> 3. Meal volumes much larger than ten-twelve ounces usually result in

> failure of weight maintenance.

> 4. The use of the thick, less distensible lesser curve of the stomach

> is believed to be important by many surgeons.

> 5. Satiety is achieved by increasing the tension on the gastric pouch

> wall, thus stimulating the stretch receptors.

> 6. Maintaining satiety is dependent upon maintaining some portion of

> that stretch for an undefined period of time.

> 7. For either the gastric bypass or the banded gastroplasty, almost

> all patients have a profound satiety, 24 hours a day, in the first

> six months or so following their bariatric surgical procedure. They

> do not redevelop a normal appetite preceding the next meal until six

> to twelve months postoperatively.

> 8. If for any reason the patient is NPO for a significant period of

> time like eight to twelve hours, a profound hunger will be

> experienced.

> 9. In the mature pouch at one plus years post-op, the more solid of

> food that a patient eats, the longer is the satiety period after the

> meal.

> 10. Almost all patients after the gastric bypass procedure, and most

> patients after the vertical banded gastroplasty, achieve fifteen to

> twenty-five minutes of satiety after simply rapidly drinking water to

> a point of fullness, or " water loading. "

> 11. Some patients fail the banded gastroplasties in association with

> shifting their diets to mostly liquids or soft solids, the " soft

> calorie syndrome, " and they fail by becoming hungry too soon before

> their next meal and giving in to snacking between meals because of

> that hunger.

> 12. Responsible patients who carefully follow the principles of using

> their " pouch/tool " continue to have a reliable and progressive weight

> loss and weight maintenance.

> 13. Patients who approach or become underweight at one to two years

> following bariatric surgery can reverse their weight loss with

> reversing the principles of using their pouch/tool.

>

> HOW DO WE INTERPRET THESE OBSERVATIONS?

>

> POUCH SIZE:

>

> It seems intuitive that the functional meal volume must stay small in

> order to limit the patient's caloric intake and provide satiety. What

> is not clear is how small it must remain. The Cottage Cheese Test,

> discussed previously, gives us some insight. With the data from that

> test, the pouch size/functional pouch volume can exceed six to seven

> ounces and still give as good a satiety as a smaller pouch.

> Obviously, this depends on patient behavior such as choices of

> specific foods eaten, frequency of meals, fluid management, and last

> but certainly not least, the amount of activity/exercise.

>

> OUTLET SIZE:

>

> The outlet of the small gastric pouch is a fixed ring, either fixed

> by scar or fixed by a band or both. There is no longer a valve that

> controls the rate of emptying. Therefore, it is intuitive that

> liquidy foods will exit the pouch faster than more solid foods.

> Certainly, no pouch can control the amount of fluid consumed, nor

> would it be tolerable if that could be done. Therefore, the calories

> contained in high calorie liquids have the ability to defeat weight

> loss or maintenance.

>

> EARLY PROFOUND SATIETY:

>

> The mechanism of action of the profound satiety of the first six

> months is presumed to be due to the necessity of the patient drinking

> water very frequently throughout the day in order to meet minimal

> fluid requirements. From our experience with " water loading, " we note

> that water loading will give almost all patients fifteen to twenty-

> five minutes of satiety if done when they are hungry. Presumably, the

> frequency of water drinking during the first six months simply

> overlaps these short periods of water-induced satiety.

> The return of appetite in our patients at about six months correlates

> with two-thirds of the pouch hyperplasia as determined by the Cottage

> Cheese Test. The average pouch size then is approximately four ounces

> when the lesser curve pouch is created at one ounce in volume at 70-

> 85 cm of water pressure. The mechanism of action is presumed to be a

> less frequent stimulation of stretch receptors in the gastric pouch

> wall because at this point the patient can ordinarily drink six to

> eight ounces of water at a time.

>

> OPTIMUM MATURE POUCH:

>

> How might we describe the optimum mature pouch? The pouch seems to

> work best when one, the outlet is not too restrictive to allow eating

> of solid foods such as meat and vegetables but two, the outlet is not

> so large as to allow early emptying and premature loss of satiety

> from solid food, and three, the pouch is not too large to allow over

> eight-nine ounces a meal.

>

> IDEAL MEAL PROCESS:

>

> What might be the ideal meal process? The ideal meal process includes

> timing of meals. To get through the day without hunger on three meals

> a day, there needs to be about five hours between breakfast and

> lunch, lunch and dinner, and dinner and bedtime. It becomes evident

> that if there are only three hours between breakfast and lunch, and

> then six to seven hours between lunch and dinner, that one cannot

> expect satiety to be maintained over the full seven hours, no matter

> how solid the food eaten, short of frank outlet obstruction. For the

> optimum meal, a more solid type of food such as finely cut meat and

> minimally cooked or raw vegetables should be eaten. The meal should

> be taken over five to fifteen minutes, depending upon the functional

> pouch volume. Stringing a meal out over thirty to forty-five minutes

> or more is one of the techniques that has been used to " beat the

> pouch. " Following the meal, take no liquids for one and a half hours,

> or even two hours if satiety is lost too soon before the next meal.

> Then, after that one and a half to two hours is up, begin drinking

> low or no calorie fluids somewhat slowly (in order to avoid over load

> symptoms if there is still considerable food in the pouch) and then

> progressively accelerate drinking up to fifteen minutes before the

> next meal. The patient should be urged to drink a lot of water in the

> two hours or so before the following meal. This period of rehydration

> ends with a " fluid load " fifteen minutes before the next meal.

> However, a single pre-meal fluid load can never adequately rehydrate

> an individual who has not already been drinking a lot of fluid. Fluid

> loading can be done any time in the two to three hours preceding the

> meal if hunger is experienced. This use of the fluid load can

> substitute for taking in unwanted calories through snacking.

>

>

>

> THE MANAGEMENT OF PATIENT TEACHING AND TRAINING

>

> Postoperative patient instruction begins with setting appropriate

> expectations preoperatively through the information provided in your

> thorough patient information booklet. This is the time to introduce

> fundamental principles such as: the small gastric pouch is a " tool "

> to gain and maintain satiety. Most patients have a fairly clear

> picture that a tool is something that one uses to perform a task but

> that the tool itself is relatively useless if it is put away on a

> shelf and not used. Patients also seem to appreciate that developing

> skill in using a tool will make the tool more effective.

>

> NECESSITY FOR LONG TERM FOLLOW-UP:

>

> We emphasize the need for long term follow up care. It is not

> possible in most patients to teach a fundamental change in lifestyle

> in " theory " by written materials given preoperatively or immediately

> postoperatively. The fine tuning of the teaching of how to use the

> pouch/tool to prolong satiety is not probably able to be accomplished

> until the patient redevelops hunger before the next meal, in the

> sixth to twelfth month postoperatively. Techniques on delaying the

> return of hunger are simply not relevant to most patients when they

> are not hungry at all, as they are not in the first six months. Even

> emphasizing preoperatively the crucial need for long term follow up

> care does not always result in patients returning as they should, but

> one must set the expectation for those who will be compliant for long

> term follow up.

>

> PREVENTION OF VOMITING

>

> We believe strongly in the principle that vomiting should be

> prevented if at all possible. This teaching begins in the hospital on

> the second postoperative day when we initially instruct the patients

> to drink only out of one ounce cups, and to drink only one-third of

> that ounce at a time with sufficient time between thirds to detect

> fullness. We emphasize that it is not easy to get used to having a

> small pouch volume. For the first few months, the patient's mouth

> will be larger than their stomach, a situation which otherwise does

> not exist in the mammalian kingdom. Also, we keep our standard

> gastric bypass patients with their small edematous outlet on liquid

> feedings for the first six weeks, gradually advancing from totally

> liquid nutrition such as

> Ensure supplemented by protein powder up through a blenderized diet

> and very soft solids. The banded gastroplasty/distal gastric bypass

> procedure with its relatively generous 7.0 cm band on its outlet is

> advanced more quickly to soft solid foods by three weeks.

> Vomiting seldom occurs in the immediate postoperative period unless

> there is an outlet obstruction problem. However, vomiting can occur

> and will do so in most patients at some time after starting on solid

> food. There are more complexities when eating solid food especially

> rice, pasta, or granola, foods that swell in the stomach after being

> eaten because they are generally incompletely rehydrated before being

> consumed. The most frequent cause of vomiting is overloading the

> pouch. We encourage patients to continue to measure their meals with

> their one ounce cups for weeks, even months, following the surgery if

> they are experiencing difficulty with vomiting. We emphasize

> repeatedly that they should eat only until " comfortably satisfied " as

> the word " full " has different meanings to different persons.

>

> SIX WEEKS

>

> Solid food is begun with emphasis on the fine cutting of fibrous food

> to the size of the fifth fingernail or smaller, thoroughly chewing,

> three or more foods at each meal to prevent wadding up of similar

> fibers, eating only until " comfortably satisfied, " and beginning,

> even at this early date, to teach the concept of no liquids with

> meals for fifteen minutes before meals and for one and a half hours

> after meals.

>

> REASSURANCE OF ADEQUATE NUTRITION

>

> Many patients need reassurance that they can achieve adequate

> nutrition in the postoperative period. Without this reassurance, some

> patients will deliberately eat six to eight times a day because of a

> fear of malnutrition (often initiated by well meaning family members

> and friends). We like to point out that in this short period of time

> during the pouch growth, there are only two major nutritional needs:

> protein on the one hand and vitamins and minerals on the other. The

> latter can easily be achieved by the patients routine twice a day use

> of the vitamin supplements. Therefore, their only responsibility and

> focus is to eat low-fat, animal-source protein at each meal, three to

> four times a day. If they do this or simply come close to doing this,

> they will end their first year post-op with a lower than pre-op lean

> body mass but one that is appropriate to their body weight at that

> time.

> (reference 4)

>

> MEAL SKIPPING

>

> On the other hand, some patients are likely to skip meals when they

> have no appetite, similar to their behavior previously when their

> appetite has been diminished by over tiredness or illness. We

> emphasize the need for three to four meals a day, including

> breakfast, primarily to meet their needs for protein. We emphasize

> that one-half or more of each meal should be composed of this low-

> fat, animal-source protein (two-thirds of their meal in the distal

> gastric bypass procedures) in the first months until their pouch

> volume is large enough so that they can eat at least two ounces of

> protein at each meal.

>

> ARTIFICIAL SWEETENERS:

>

> We warn our patients to be aware of using artificial sweeteners if

> they are experiencing hunger in this early p.o. period. We have

> evaluated a few patients who experienced very strong hunger cravings

> in the first weeks or months post-op whose hunger abruptly ceased

> with stopping artificial sweeteners.

>

> AVOIDING ABSOLUTES

>

> There are so many rules that we teach concerning the use of

> the " pouch/tool " that we believe that it is important to emphasize to

> the patient that it is not necessary to follow every rule all of the

> time. We actually suggest that it is perfectly all right to break the

> rules once in a while- the important thing is to be aware that one is

> breaking the rule and having a reason for it even if that reason is

> simply alleviating frustration. We point out that the only penalty

> for eating a liquidy meal when appetite has returned is the earlier

> return of hunger in the next four to five hour period. There is no

> lasting effect beyond that next meal. We also point out that deciding

> to take advantage of a social opportunity to eat a high calorie,

> empty calorie meal is the ingestion of a relatively insignificant 600

> to 1,000 calories instead of the 3,000 to 5,000 calories that could

> be consumed in such a meal with a normal stomach volume.

>

> THREE MONTHS

>

> At three months we step up the teaching of the nutritional or protein-

> containing value of foods related to the " cost " of that protein food

> in terms of calories consumed, i.e. a gram of cottage cheese

> protein " costs " only five calories, but a gram of cheddar cheese

> protein costs sixteen calories, and peanut butter twenty-four

> calories. Water loading techniques (see below) are introduced at

> three months postoperatively as some patients will begin to see a

> return of appetite before their six month office visit. Overall fluid

> management is discussed, emphasizing how the Gastric Emptying Test

> illustrates the principles of fluid management (see below).

>

> THREE PRINCIPLES FOR GAINING AND MAINTAINING SATIETY

>

> 1. The pouch needs to be truly filled with adequate wall distention

> with each meal (i.e. no snacking).

>

> 2. Keep the pouch filled over time and slow down the emptying time

> (by eating solid foods and avoiding liquids for fifteen minutes

> before and one and one half to two hours after eating. We understand

> this to be the most important lifestyle change after the gastric

> bypass procedure. Figure 3 shows the results of a standard gastric

> emptying test using radioactive sulfur with a scrambled egg, bread,

> and milk. With the milk, 90% of the meal volume has exited the

> stomach within forty-five minutes. However, without the milk, only

> 45% of the meal has exited the stomach by ninety minutes.

>

> 3. Finally, adequate protein with each meal. We emphasize three meals

> a day including breakfast (defined as the first meal of the day which

> is eaten within one to two hours after arising). We define

> the " enemy " as high calorie liquids. We point out that snacking and

> high calorie liquids cheat the patient because the calories are taken

> in without offering significant satiety.

>

> FLUID LOADING

>

> Fluid loading is the rapid drinking of a non-calorie or low-calorie

> liquid on an empty stomach in order to achieve a maximal intake of

> water at that time and/or achieve immediate satiety which lasts for

> fifteen to twenty-five minutes. About 80% of the estimated maximum

> capacity at any given time should be drunk rapidly over fifteen to

> thirty seconds and then topped off with swallows until full satiety

> is reached. Patients rather rapidly determine what their capacity is,

> and it usually is between eight to twelve ounces when the Cottage

> Cheese Test volume is four to six ounces. The fluids should not be so

> cold as to be uncomfortable, but it is not necessary to be warm. The

> mechanism of action is presumed to be the distention of the Roux limb

> with subsequent contraction, stopping the progression of fluid

> downwards and backing up the volume and pressure into the small pouch

> and, perhaps, even into the distal esophagus. Fluid loading works

> with the banded gastroplasty as well but not quite as effectively.

> The mechanism here is probably primary distention of the pouch with a

> fluid as it is passing through. The volume required is usually

> somewhat greater, but it still is far less than two to four glasses

> of water required in a normal sized stomach. Clearly, this small

> proximal pouch is quite sensitive to distention, and the satiety

> gained from that distention lasts far longer than the distention

> itself. We teach patients to fluid load before each meal in order to

> help prevent post meal thirst, but also to fluid load whenever they

> feel the sensation of hunger and are tempted to snack.

>

> POST PRANDIAL THIRST:

>

> It is important that the patient be fully hydrated before coming to

> the next meal because the solute load of the meal will create

> postprandial thirst. It seems intuitive that persons cannot tolerate

> thirst any more than they can tolerate hunger over the long run as

> both hunger and thirst are primary noxious stimuli. Initially, when

> the functional pouch volume is quite small, the solute load is

> correspondingly small, and the patient may not see the point of

> adequate rehydration and pre-meal fluid loading. However, as the

> pouch volume increases and the solute load increases, it becomes a

> significant issue in maintaining that important proscription of

> avoiding liquids during and for an hour and a half after the meal.

>

> URGENCY

>

> In these first months we like to emphasize to patients that their

> golden opportunity for maximizing their weight loss is in the first

> six months after surgery. We illustrate this with the weight loss

> curve, with its rapid downward sweep, with two-thirds of their weight

> being lost in the first six months postoperatively. The Cottage

> Cheese Test shows that two-thirds of the pouch growth occurs in the

> first six months. Therefore, we teach our patients that every day

> during this early period the exercise and activity that they do will

> be more effective in burning calories in excess of their calorie

> intake than the same amount of activity/exercise the following

> day. . . and a little less effective than the previous day based on

> progressive pouch growth. I.e. every single day the patient should

> take advantage of their present opportunity and get as much activity

> as they can, knowing that never again will that same amount of

> activity result in as much weight loss. We try to give them a sense

> of urgency about getting the most out of every day.

>

> SIX MONTHS

>

> At this point, or soon after, our patients are beginning to get

> hungry before their next meal, and we accelerate the teaching of

> satiety mechanisms and the prevention of post meal thirst. As the

> meal solute volume increases, they need to push enough fluids in the

> two to three hours before the meal to gain good hydration with final

> water loading fifteen minutes before the next meal.

>

> INTAKE INFORMATION SHEET AS A TEACHING TOOL

>

> At each visit from three months to two years, the patient is asked to

> complete a form before they come into the office. The form queries

> them about their performance on the principles of pouch use (as well

> as vitamin usage, exercise, pathological symptoms, etc.). This form

> is designed so that it is also a teaching tool- each question reminds

> the patient about the principles of the use of their pouch/tool.

> Many, if not most, patients do very well, and their weight loss is

> progressive and satisfying. Some struggle to make the lifestyle

> changes necessary, but with these periods of intermittent monitoring,

> encouragement, and teaching they progressively learn and most do

> well. A few patients never seem to understand or to remember these

> simple principles even though they might be quite intelligent,

> capable persons in other facets of their lives. . .

>

> HONEYMOON SYNDROME

>

> The profound satiety that patients experience in the first six

> months, along with the rapid weight loss due to intake restriction,

> can lead certain patients to believing that these circumstances will

> never change in spite of the clear teaching of our patient

> information booklet and clinic visit handouts. For these patients, we

> will then see a slackening off on their food selection and liquid

> calorie control and see them indulge in more recreational eating.

> They will cut back on their exercise as they seem to be losing a

> great deal of weight without exercising. Their weight loss will

> subsequently slow. We have dubbed this situation the " honeymoon

> syndrome " and tried to educate our patients, even in our preoperative

> informational booklet, that they can expect this temptation to occur

> and that they must not get " suckered " into a false sense of comfort

> that leads them to not make a sufficient effort in their own behalf

> and miss this golden opportunity for weight loss. We have found that

> an effective tool for identifying and reality-orienting the patient

> is to graphically compare that patient's weight with the mean weight

> loss of the group as a whole. Whatever the patients beginning weight

> is, we would expect them to parallel the weight loss curve. If their

> weight deviates from the expected, we should be able to find a reason

> for it and to correct it if the patient is willing to learn and make

> this needed lifestyle change.

>

> EXERCISE

>

> Although this chapter is about understanding the function of the

> small proximal gastric pouch and how it relates to patient

> management, a word must be mentioned about exercise. We believe that

> the scientific data overwhelmingly demonstrates that 1) exercise is a

> critical part of a healthy lifestyle for patient and doctor alike,

> and 2) that exercise is necessary to maintain weight loss in the

> obese patient. Therefore we believe it must be a critical part of our

> postoperative patient teaching and encouragement. Exact details are

> beyond the scope of this presentation, but we do emphasize to the

> patients that the feelings of vigor and energy are in no way

> guaranteed by a slender figure. Observations of people on any city

> street confirm this. . . We emphasize that the release of endorphins

> with aerobic exercise improves emotional stability and mental clarity

> and helps any person to cope with the deprivations and annoyances of

> everyday life. Endorphins, adrenalin, norepinephrine, etc., also act

> in an antidepressive manner. But most importantly, especially in the

> first six month period when the gastric pouch is so small, regular

> aerobic exercise maintains, or even improves basal metabolic rate

> that is observed to drop during rapid weight loss.

>

> THE IDEAL MEAL FOR WEIGHT LOSS

>

> The ideal meal for weight loss is one-half of the meal volume up to a

> total volume of two to three ounces of animal-source, low-fat protein

> plus filling the rest of the pouch volume with low starch vegetables

> and solid type fruits such as apples and pears. Cut finely and chewed

> well, these foods represent coarse, solid food choices that are

> likely to stay in the pouch longer and offer good nutritional value.

>

> VOLUME VERSUS CALORIES

>

> A person with a normal stomach tends to judge how much he/she needs

> to eat at a given meal by approximately how many calories are in that

> meal (although not necessarily thinking of calories as such). In

> other words, we know that we are going to be unpleasantly hungry

> before dinner if our noon meal consists of a green salad and a couple

> of ounces of cottage cheese. Calories are what keep us from getting

> hungry between meals. On the other hand, the post-op gastric bypass

> patient needs to learn to think about the volume and consistency of

> food choices rather than their caloric content when judging how to

> prevent getting hungry before the next meal. I recall a lecture I

> once attended in which the lecturer pointed out that one or two

> sticks of butter could meet our entire calorie needs for the day and

> could be easily consumed by even the small post-op gastric bypass

> pouch. However, that same number of calories in the form of non-

> starchy raw vegetables could not be consumed by a person with a

> normal stomach in only three meals a day. There is an enormous

> variation between calories and volume, and a patient needs to learn

> how to " think volume " when making food choices to gain and maintain

> satiety in a mature small gastric pouch.

>

> ISSUES FOR LONG TERM WEIGHT MAINTENANCE

>

> The previous comments are primarily designed to deal with patient

> issues in the first year following a gastric bypass procedure. These

> issues should seamlessly slide into long term weight maintenance and,

> indeed they do so in most persons.

>

> COUNTER-INTUITIVENESS OF FLUID MANAGEMENT:

>

> It is clear that avoiding liquids with meals and pushing fluids

> between meals is counter intuitive. The large capacitance of a normal

> stomach is a great convenience factor for that person and, truly, all

> animal life. There is a resistance to learning this technique, and

> clearly it is counter intuitive to the experience of the individual.

> However, if it is important that solid food be taken rather than

> liquidy food to maintain satiety, then it is clearly important to

> avoid liquids with meals or soon after meals as the liquid will

> simply make the food more soup-like and soft and allow more rapid

> emptying of the pouch and, therefore, shorten the period of satiety.

>

> SUPPORT GROUPS

>

> We have found that support groups are very effective in reinforcing

> the principles of the pouch/tool use. Many, if not most, patients

> will explore these principles on their own by using them and then for

> a time not using them. Some patients on their own become convinced of

> the value of these principles through this natural experimentation.

> However, others may lose their way. The support group offers an

> excellent feedback mechanism for individuals who need reinforcement

> of the principles of the pouch use. Sometimes, the feedback of their

> peers is more effective than that of the parental figures in the

> surgeon's office.

>

> TEETER-TOTTER EFFECT

>

> One " visual " that we use when discussing weight maintenance is that

> of a teeter-totter. On one end of the teeter-totter is the

> exercise/physical activities, and on the other end is the meal choice

> discipline and fluid restrictions. When one has a large amount of

> exercise and activities, the teeter-totter swings down on that end,

> and the amount of effort that need be placed on diet discipline

> lightens up. When one is light on the activity/exercise, one has to

> be much heavier on the diet discipline side. If one is light on both

> exercise and diet discipline, the whole teeter-totter moves upward as

> weight is gained. On the other hand, if one is " heavy " on both

> exercise and diet discipline, the teeter-totter bar goes down, and

> weight is lost.

>

> TOO MUCH WEIGHT LOSS

>

> There are a group of patients in our practice, approaching 15%, who

> lose too much weight in the one to two year period postoperatively.

> Inevitably, these individuals were only 100 to 150 pounds overweight

> to start with and are good exercisers. We encouraged them to taper

> off their efforts with diet discipline (maintaining their exercise

> routine and thus their vigor) by adding some fat back to their meals

> and eating a fourth or fifth meal a day with less discipline on the

> fluid management. Basically, it is an exercise on " how to beat the

> pouch. " The pouch can be beaten by one, liquid high calorie meals;

> two, frequent meals or grazing; three, eating a meal over thirty to

> forty-five minutes; four, adding liquid to meals to enhance gastric

> emptying; five, liquids are taken shortly after eating which

> increases gastric emptying and decreases the satiety period. Some

> patients take our advice and taper off their weight loss before they

> go underweight. However, a small but significant group of patients

> actually go underweight because all of our patients have experienced

> the rapid and frightening return of severe hunger cravings when going

> from one of their many diets to trying to eat normally once again.

> Very similar to a bear coming out of hibernation, their suppressed

> appetite center seems to burst out with vigor in order to save the

> life of this person who the appetite center sees as a normal weight

> person having suffered in a famine. Many patients at this point have

> not yet fully accepted that they have had a true anatomic and

> physiologic change from their operation and that, using the

> principles of the pouch/tool, a return of this overwhelming appetite

> will not occur. For these persons, it is not until their lean body

> mass is effected and they lose their delightful sense of vigor that

> they will begin to " break the rules " and gain some needed weight

> back. This is probably the primary reason why, in most bariatric

> surgical practices, the weight loss curve bottoms out at eighteen to

> twenty-four months with a rise at two to three years. This rise has

> been erroneously interpreted as most patients regaining 10% to 15% of

> weight from the nadir of their weight loss.

>

> BARIATRIC MEDICINE

>

> A much more common problem is that of patients who have not lost as

> much weight as they would like and are plateauing at a level above

> their goal weight. Bariatric medicine techniques can be useful in

> helping our postoperative patients who find themselves stuck on a

> plateau one or more years postoperatively. However, there can be a

> problem with standard weight control and dietary teaching of

> Bariatric medicine. The frequently used recommendations of frequent

> small feedings or liquid calorie fasts such as a protein sparing

> modified fast, neutralizes the satiety function of the pouch/tool,

> and tends to negate the teachings of the principles of the pouch use,

> and therefore is probably not an optimum way of managing the patient.

>

> SUMMARY

>

> The principles of the postoperative bariatric surgical follow up

> management are as follows:

> 1. Understanding the fundamentals of the anatomy and physiology of

> the pouch/tool.

> 2. Evaluating the patient's appropriate or inappropriate use of the

> tool- What is lacking? What is being done well?

> 3. Instruct patient with words, drawings, analogies, encouragement,

> and passion, on not only what to do but why it needs to be done.

>

> The goal is to make the patient become fully knowledgeable about how

> to control their own weight over the long term through the

> appropriate use of their pouch/tool, combined with a reasonable

> amount of exercise.

>

> EVALUATION FOR WEIGHT LOSS FAILURE

>

> Evaluating a patient who is progressively regaining weight can be

> relatively simple- or extremely difficult. The first principle is to

> determine that the gastric pouch is anatomically intact. If it is not

> intact, it should be made intact by a revision procedure. Only when

> the surgeon can be reassured that the pouch is intact does the

> complex part begin- evaluating how and why the patient is not using

> the pouch/tool properly, and/or getting a reasonable amount of

> exercise.

>

> We need to know three things about the small gastric pouch. First, is

> the staple line intact; second, is the outlet intact; and third, is

> the pouch reasonably small in size.

>

> The upper GI series with thick barium is the basic tool for

> evaluating intactness of the staple line and the outlet. If the pouch

> has been stapled in continuity with the rest of the stomach, we must

> confirm that the staple line remains intact. An eventration of the

> staple line will create two gastric outlets leading to rapid pouch

> emptying, early loss of satiety, and thus early return of hunger. An

> important clue from the patient's history is the presence of a

> marginal ulcer after a gastric bypass. Marginal ulcers do occur,

> occasionally, with an intact staple line. However, they are more

> common with a small hole in the staple line that results in food

> stimulation of the antrum. If there is a staple line eventration, the

> marginal ulcer is unlikely to be able to be controlled without

> reoperation and closure of that eventration, preferably with complete

> division of the small pouch from the distal stomach.

>

> The upper GI series with thick barium in the hands of an experienced

> radiographer can usually give the bariatric surgeon a reliable view

> of the diameter of the gastric outlet. A diameter of over 18-20

> millimeters is usually associated with weight regain, and we term

> this " outlet failure. " Outlet failure, like a staple line

> eventration, causes rapid emptying of the pouch, early loss of

> satiety, and early return of hunger.

>

> On the other hand, weight regain can occur as a result of an outlet

> diameter under 7-8 millimeters which can lead to persistent vomiting

> of solid foods and gradual persuasion of the patient towards the Soft

> Calorie Syndrome with resultant rapid pouch emptying, early loss of

> satiety, early return of hunger, and weight regain.

>

> The upper GI series is less effective for evaluating pouch volume

> because of the fact that barium is very much of a liquid. To assess

> pouch volume, you must turn to the patient's history of the size of

> the meal that he/she can consume within a short five to fifteen

> minute time frame, and/or to the Cottage Cheese Test (see above).

>

> In the patient whose gastric pouch seems to be anatomically intact

> and yet he/she is still regaining weight, the evaluation becomes more

> complex. The usual finding is that the patient is not following the

> principles of the use of their pouch/tool and/or is extremely

> inactive physically. There are four problems that occur with some

> frequency: the patient has never been taught/or does not understand

> how to use the tool; the patient is significantly depressed; or loss

> of contact with a bariatric practice and other bariatric patients and

> a gradual erosion of following the principles; or the patient is

> truly noncompliant and will not take responsibility for his/her own

> behavior.

>

> LACK OF TEACHING

>

> An excellent example of the lack of teaching/understanding of how the

> pouch works is found in the history of GC. GC is a 62-year-old woman

> who presented in consultation for a total regain of her weight and

> complaint of constant hunger, sixteen years following a gastric

> bypass procedure in Cambridge, Massachusetts. She stated that she had

> not seen the surgeon beyond the six week follow up visit. She

> understood nothing about how to use her gastric pouch. She initially

> lost fifty pounds and then another forty pounds further with the help

> of a commercial weight management program. For the next ten years she

> yo-yoed up and down with the usual peer group and doctor supported

> programs with a gradual increase in weight and the usual hunger and

> deprivation syndromes relating to these programs. She then developed

> myasthenia gravis and her weight regain escalated to her preoperative

> weight, resulting in the referral. At the time of the referral she

> was being treated effectively for myasthenia gravis and was

> reasonably active, being able to walk over a mile at a time. Her

> weight loss curve with its abrupt turn around and rapid weight loss

> (figure 4) could be consistent with a revision reoperation. However,

> there was no revision done. After evaluation of her pouch/tool with

> an upper GI series and a Cottage Cheese Test/functional meal volume

> estimation, she was given the basic instructions of how to use her

> pouch/tool, the same given to all of our postoperative patients. Her

> ensuing and continuing weight loss is impressive, but more impressive

> to the patient is that she is not experiencing any distressing hunger

> cravings, food fantasies, or food dreams as she had experienced with

> all of her previous efforts, since the first months after her gastric

> bypass procedure sixteen years ago.

>

> DEPRESSION

>

> Depression is a powerful inhibiter of success after bariatric

> surgical procedures. A small but significant number of our patients

> have been doing well following their gastric bypass procedure only to

> drop out of sight for a time and then reappear with a significant

> weight regain. Upon evaluating these patients, it would appear that

> in many instances they seemingly deliberately reverse all of their

> learned principles of the use of their pouch/tool: grazing and

> snacking through much of the day, drinking high calorie liquids,

> drinking liquids with meals, and stopping their exercise, even when

> they are intellectually aware that exercise in itself releases

> numerous vasoactive substances which act like antidepressants. DB is

> a 46-year-old woman who had an excellent initial weight loss

> following a gastric bypass procedure (figure 5). While still in the

> first year after her gastric bypass, her life, already made difficult

> by divorce and economic circumstances, became severely disrupted when

> her only daughter developed a drug problem, an abusive relationship,

> and finally HIV, and was forced to give up her newborn child. Her

> weight regain was dramatic. However, even more dramatic was her

> weight loss once her depression eased, and she was able to look after

> herself once again. She relates that she did nothing dramatic such as

> fasting. She simply returned to using her pouch/tool in the manner in

> which she had been taught and resumed a moderate exercise program.

> What can the bariatric surgeon do when patients are obviously

> depressed and regaining weight? Obviously, the most important thing

> is to steer them to professional counseling, if they are not already

> in counseling. Then, the surgeon can be encouraging. We can encourage

> them to continue to use the tool as best as they can; we can

> encourage them to return to exercise which will improve the spirits

> and reassure them that the improvement is " deserved, " " because you

> really are a good person, and you deserve to feel better. . . " Most

> of all, the surgeon can reassure them that the pouch/tool is not

> ruined by this overeating and gradual weight regain if it does not

> result in persistent vomiting of solids. When they are ready once

> again to use their pouch/tool, it will be there for them, and they

> will be able to once again lose weight without being hungry.

>

> EROSION OF THE USE OF THE PRINCIPLES:

>

> In a third subset of weight maintenance failure patients, a subtle

> weight creep can occur to patients who are otherwise compliant, non-

> depressed, and have intact pouches. The patient will see it

> as " struggling " with his/her weight, and by definition, he/she will

> not have seen you in follow up and will have usually lost contact

> with the support group or other bariatric surgical patients. There

> seems to be a progressive erosion of following the principles of the

> pouch/tool use. This may be due to denial as seen in diabetic

> patients, or it may be due to the influence of their peer group and

> the fact that some of the principles of the use of the pouch/tool,

> especially fluid management, are counter- intuitive and counter to

> behavior of their peer group. The patient will often not come back

> for evaluation because " I know what I'm doing wrong! " (meaning that

> he/she is eating the wrong things and too often), and these patients

> will internalize their " failure " with an increasing sense of guilt

> which itself acts as an inhibition to coming back to their surgeon's

> office for help.

> From the beginning, in our preoperative teaching, we emphasize the

> possible need for a " refresher course " in the use of the principles

> of the pouch/tool at some time in the future. Some patients still do

> not return. The trick is identifying these patients and somehow

> getting them back either into the office or into a support group.

> In these three examples- lack of teaching, depression, and gradual

> erosion of the use of their tool, weight once regained can be lost

> once again if the pouch is anatomically intact and the patient

> decides to use it, or learns how to use it or relearns how to use it.

> In these three examples, we are working with compliant, reasonably

> responsible persons who, when they can, are willing to take

> responsibility for their own behavior.

>

> TRUE NON COMPLIANCE:

>

> The most difficult problem is determining, and being comfortable with

> that determination, when a patient is being fundamentally

> noncompliant and obstructive. This type of individual may leave your

> care and go to others complaining about a " personality conflict, " or

> perhaps even that you have not given them the time and attention that

> they need and deserve. Inexplicably, some will actually stay in your

> care. In this instance, when the patient tends to return perhaps even

> more frequently than usual, depression will be more likely the

> underlying mechanism rather than noncompliance. It can be difficult

> to be reasonably sure of what is going on in one or two visits. The

> truly noncompliant patient will very likely end up with multiple

> revisions and/or a reversal due to weight regain or complications.

> This kind of patient is often quite resistant to counseling, but I

> know of no other management option that offers much hope for success.

> Luckily, this type of patient represents a very small minority of our

> patients. Obviously, prevention in the form of patient selection is

> better than cure, but after twenty-three years of a bariatric

> surgical practice, I have yet to be able to effectively identify

> these persons preoperatively. I have, in fact, suspected significant

> noncompliance in a number of my patients who have turned out to be

> quite compliant particularly after control of other problems, such as

> sleep apnea, that effect understanding and complying with our

> instructions. With the current lack of an effective psychological

> screening tool to reliably identify these individuals, I tend to lean

> towards giving each person a chance at a good and healthy life

> provided by bariatric surgery.

>

> BIBLIOGRAPHY

> 1) Mason, EE, Personal Communication, 1980

> 2) Barber, W, Diet al, Brain Stem Response To Phasic Gastric

> Distention. Am J. Physiol 1983; 245(2): G242-8

> 3) Flanagan, L. Measurement of Functional Pouch Volume Following the

> Gastric Bypass Procedure. Ob Surg 1996; 6:38-43

> 4) Rosemurgy, A.

>

>

>

>

>

>

>

>

>

[Guest guest]

This is good information and we would all do well to study it. I am immediately

going to implement the hydration suggestions and the info about the solids in

the meals. It makes sense, and I am immensely heartened to read about

correcting weight problems years later with following the correct use of our

" tool. "

Thanks so much for finding and sharing this article.

Pat

Drinking/thirsty

Here is an article that might shed some light on the drinking etc. with meals

along with some other information. Now although it was not written by our

beloved Dr. R, (Dr. R feel free to chime in, maybe he even knows the Dr. that

wrote this,) there is some information I have found useful.

POST-OP TEACHING AND EVALUATION

By Latham Flanagan, Jr., M.D., FACS

Article is sectioned by capitalized categories.

INTRODUCTION

>From our earliest experiences in bariatric surgery, we have been

intrigued with the question " How does our operation cause weight loss

and maintenance? " As we talked to the public, and even our medical

peers, it became evident that a common concept of the uninformed is

that the small gastric pouch simply mechanically restricts intake,

preventing the post-op patient from eating too much. Indeed,

superficially, it may appear that way especially in the first 3-9

months post-op. However, even a short experience with following our

patients shows us that with a meal size of even three to five ounces,

certain patients will stop losing weight and start to regain. We also

note that two to five or more years postoperatively certain patients

seem to have a large meal volume of six to ten ounces but still

maintain good weight control without an noxious degree of hunger. It

has become clear with experience that the principle of weight control

is the achievement of satiety, or the absence of abnormal hunger,

associated with the ingestion of the appropriate number of calories

sufficient to meet the person's need. If adequate satiety is

achieved, our patients are successful. . . And they fail if that

satiety is not achieved. When patients " fail " there is a tendency,

even among bariatric surgeons, to pass it off as " noncompliance. "

Certainly, this can be an appropriate evaluation in a few persons who

are not willing to accept responsibility for the lifestyle changes

necessary to make the small gastric pouch function properly. But, is

this the problem for the majority? I think not. When failure does

occur, it is usually the inability to maintain the post meal satiety

long enough to prevent snacking before the next meal time arrives.

Also, it could be due to ingestion of a large number of calories in a

form that is somewhat hidden to the patient and is not responsive to

the gastric pouch restriction, especially high calorie liquids.

HYPOTHESES OF POUCH FUNCTION:

At this point in time what have we learned about how the small

gastric pouch works? In the form of an hypothesis, we can now state

that the basic mechanism is that of stretch of the pouch walls with

eating of a small meal, or even the drinking of fluid. This stretch

is sensed by the stretch receptors in the pouch wall and relayed by

neural pathways to the appetite centers in the hypothalamus by way of

the tractus and nucleus solitarius. The second hypothesis is that

successful maintenance of satiety depends upon the creation and

maintenance of a small gastric pouch and a small gastric pouch outlet

(Mason- reference 1). The third hypothesis is that the observed

increase in functional meal volume over the months and years

following a gastric bypass procedure is due to the process of

hyperplasia and is not wholly or in great part due to noncompliance

on the part of the patient. The fourth hypothesis is that

understanding of these principles and effective teaching to a

compliant patient results in better weight loss and maintenance than

if the teaching is not accomplished.

PUBLISHED DATA

To support these four hypotheses, we have two pieces of reasonably

good scientific information from peer reviewed published articles.

From that point we must rely on observational-based science.

Our first question is how does the small gastric pouch create

satiety? Considerable insight on the neurological pathways of satiety

has been obtained through the work of Barber, a Ph.D.

veterinarian, and his associates who published a paper in 1983

entitled " Brain Stem Response to Phasic Gastric Distention. "

(reference 2) They placed a balloon in the stomachs of anesthetized

cats and surrounded the stomach with a strain gauge. Microelectrodes

were placed in the nucleus and tractus solitarius of the brain stem.

They found a population of neurons that faithfully monitor moment to

moment changes in gastric wall tension. The discharge frequency to

wall tension did not adapt for the twelve hour period of the

experiment. This response was dependent upon an intact vagal nerve in

these cats. They concluded that " these neurons may serve as a

critical link between the stomach and higher centers in the conscious

perceptions of fullness. " It seems particularly impressive and

interesting that the neurons continued to fire at an accelerated rate

for as long as twelve hours, if the gastric wall tension remained

high.

Another question of considerable importance to the thinking of a

bariatric surgeon is what is the fate of the small gastric pouch?

Does it enlarge at all after the surgical procedure? If it does

enlarge, is it because the operation was done improperly? Was it

because of gross patient noncompliance and gorging? Or, is it due to

the kind of hyperplasia seen throughout the gastrointestinal tract, a

response to loss of function? Dr. E. E. Mason, at one of the Iowa

Bariatric Symposia in the early 1980's, suggested that it might be

useful to ask patients to eat cottage cheese in a structured manner

in order to attempt to determine their functional meal volume at

different times postoperatively. I took the idea home and began

asking all of my patients to do this simple test with each one of

their follow-up postoperative visits at three, six, nine, twelve,

eighteen, and twenty-four months. We continued to do this over the

next decade (and subsequently to date), and figure 1 reveals a

regular, progressive, stepwise increase in functional pouch volume

over time that strongly suggests the orderly process of hyperplasia.

Stabilization occurred at two years at a mean pouch size of six

ounces with a wide range of three to nine-ten ounces. The pouch

appears to not get larger after the second year. (reference 3) These

gastric bypass pouches were created as a vertically oriented, 30 cc

pouch measured against both volume and pressure of 70 to 85 cm of

water. The curve of pouch enlargement is the inverse of the weight

loss curve.

We then proceeded to compare the patients' weight losses at one and

three years to pouch sizes at one year. Figure two reveals that there

was no difference in percent excess weight loss at one year, with the

different pouch sizes within this range of up to nine-ten ounces. We

then compared the largest third of pouch sizes to the smallest third

of pouch sizes, and still there was no significant difference in

weight loss at one year or of maintenance at three years. This

finding is, perhaps, the most important result to come from the

Cottage Cheese Test work. It strongly suggests that within these

limits of pouch sizes that success in weight loss and maintenance

depends not only on having a small gastric pouch but even more so in

how the patient uses their " pouch/tool. " If this is true, then the

implication is clear that learning how to use the pouch/tool

effectively is important and that it is our responsibility as

bariatric surgeons to see that effective teaching is made available

to our patients over this two year period of changing intake and

satiety control. In brief, the Cottage Cheese Test data tells us that

within the context of a small meal volume, lifestyle change including

exercise is the most important variable. The stepwise progressive

growth in the functional pouch volume (meal size) probably defines

the rate of weight loss for the patients taken as a whole, but the

degree of weight loss and maintenance for the individual patient is

more dependent upon that patient's ability to make the required

lifestyle changes: proper use of the pouch/tool and adequate amounts

of activity and exercise.

OBSERVATIONAL-BASED MEDICINE

Observational-based medicine has a long history of respect going back

to the early work of two of my personal surgical heros, s

Vesalius and Ambrose Paré. Indeed, we often refer to the " art and

craft of surgery " . Although we do make great effort to have a

scientific basis to our surgical decision making, ideally with

prospective randomized studies or double blinded studies, at this

point in time the majority of what we do is based on empiricism, or

observational-based medicine. The observations that I would now like

to share from my own personal thirty-three years of experience in

bariatric surgery are also shared by many other experienced bariatric

surgeons of my acquaintance, although not all would agree with all of

these principles.

For the first fifteen years, although I remained busy in a general

surgical practice, my primary interest, bariatric surgery, lagged

because of the lack of patient material, primarily because of the

profound discrimination of medical insurers against the morbidly

obese in our area of the country. What appeared to be a disadvantage

initially became an advantage, as I thereby had the opportunity to

follow almost all of my patients personally during that time. As

there was little known about the mechanism of action of the gastric

bypass procedure, I spent a good deal of my time thinking about

possible mechanisms and observing the differences between patients

with good weight loss and those with poor weight loss. Since the

beginning, I have performed the short limb gastric bypass procedure

(GBP), only adding the malabsorption procedure of the banded

gastroplasty/distal gastric bypass procedure (BG/DGB) in 1992. The

BG/DGB also uses a small, vertically oriented gastric pouch quite

similar to the gastric bypass procedure pouch, the difference being

that the outlet is controlled by a band as in the vertical banded

gastroplasty and silicone ring gastroplasty, etc., instead of a

gastroenteric anastomosis. My observations seemed to be similar for

the two procedures, although not identical for both. The Cottage

Cheese Test was done only with the GBP. Considering the above, what

do I think that I have learned?

The following are observations that may have an effect on the

function of the gastric bypass pouch:

1. We have come to understand that the accomplishment of satiety, or

suppression of hunger, is fundamental to the success or failure of

bariatric operations.

2. We have come to understand that success relates anatomically to

creating a small pouch that remains relatively small and a small

outlet that remains relatively small (Mason).

3. Meal volumes much larger than ten-twelve ounces usually result in

failure of weight maintenance.

4. The use of the thick, less distensible lesser curve of the stomach

is believed to be important by many surgeons.

5. Satiety is achieved by increasing the tension on the gastric pouch

wall, thus stimulating the stretch receptors.

6. Maintaining satiety is dependent upon maintaining some portion of

that stretch for an undefined period of time.

7. For either the gastric bypass or the banded gastroplasty, almost

all patients have a profound satiety, 24 hours a day, in the first

six months or so following their bariatric surgical procedure. They

do not redevelop a normal appetite preceding the next meal until six

to twelve months postoperatively.

8. If for any reason the patient is NPO for a significant period of

time like eight to twelve hours, a profound hunger will be

experienced.

9. In the mature pouch at one plus years post-op, the more solid of

food that a patient eats, the longer is the satiety period after the

meal.

10. Almost all patients after the gastric bypass procedure, and most

patients after the vertical banded gastroplasty, achieve fifteen to

twenty-five minutes of satiety after simply rapidly drinking water to

a point of fullness, or " water loading. "

11. Some patients fail the banded gastroplasties in association with

shifting their diets to mostly liquids or soft solids, the " soft

calorie syndrome, " and they fail by becoming hungry too soon before

their next meal and giving in to snacking between meals because of

that hunger.

12. Responsible patients who carefully follow the principles of using

their " pouch/tool " continue to have a reliable and progressive weight

loss and weight maintenance.

13. Patients who approach or become underweight at one to two years

following bariatric surgery can reverse their weight loss with

reversing the principles of using their pouch/tool.

HOW DO WE INTERPRET THESE OBSERVATIONS?

POUCH SIZE:

It seems intuitive that the functional meal volume must stay small in

order to limit the patient's caloric intake and provide satiety. What

is not clear is how small it must remain. The Cottage Cheese Test,

discussed previously, gives us some insight. With the data from that

test, the pouch size/functional pouch volume can exceed six to seven

ounces and still give as good a satiety as a smaller pouch.

Obviously, this depends on patient behavior such as choices of

specific foods eaten, frequency of meals, fluid management, and last

but certainly not least, the amount of activity/exercise.

OUTLET SIZE:

The outlet of the small gastric pouch is a fixed ring, either fixed

by scar or fixed by a band or both. There is no longer a valve that

controls the rate of emptying. Therefore, it is intuitive that

liquidy foods will exit the pouch faster than more solid foods.

Certainly, no pouch can control the amount of fluid consumed, nor

would it be tolerable if that could be done. Therefore, the calories

contained in high calorie liquids have the ability to defeat weight

loss or maintenance.

EARLY PROFOUND SATIETY:

The mechanism of action of the profound satiety of the first six

months is presumed to be due to the necessity of the patient drinking

water very frequently throughout the day in order to meet minimal

fluid requirements. From our experience with " water loading, " we note

that water loading will give almost all patients fifteen to twenty-

five minutes of satiety if done when they are hungry. Presumably, the

frequency of water drinking during the first six months simply

overlaps these short periods of water-induced satiety.

The return of appetite in our patients at about six months correlates

with two-thirds of the pouch hyperplasia as determined by the Cottage

Cheese Test. The average pouch size then is approximately four ounces

when the lesser curve pouch is created at one ounce in volume at 70-

85 cm of water pressure. The mechanism of action is presumed to be a

less frequent stimulation of stretch receptors in the gastric pouch

wall because at this point the patient can ordinarily drink six to

eight ounces of water at a time.

OPTIMUM MATURE POUCH:

How might we describe the optimum mature pouch? The pouch seems to

work best when one, the outlet is not too restrictive to allow eating

of solid foods such as meat and vegetables but two, the outlet is not

so large as to allow early emptying and premature loss of satiety

from solid food, and three, the pouch is not too large to allow over

eight-nine ounces a meal.

IDEAL MEAL PROCESS:

What might be the ideal meal process? The ideal meal process includes

timing of meals. To get through the day without hunger on three meals

a day, there needs to be about five hours between breakfast and

lunch, lunch and dinner, and dinner and bedtime. It becomes evident

that if there are only three hours between breakfast and lunch, and

then six to seven hours between lunch and dinner, that one cannot

expect satiety to be maintained over the full seven hours, no matter

how solid the food eaten, short of frank outlet obstruction. For the

optimum meal, a more solid type of food such as finely cut meat and

minimally cooked or raw vegetables should be eaten. The meal should

be taken over five to fifteen minutes, depending upon the functional

pouch volume. Stringing a meal out over thirty to forty-five minutes

or more is one of the techniques that has been used to " beat the

pouch. " Following the meal, take no liquids for one and a half hours,

or even two hours if satiety is lost too soon before the next meal.

Then, after that one and a half to two hours is up, begin drinking

low or no calorie fluids somewhat slowly (in order to avoid over load

symptoms if there is still considerable food in the pouch) and then

progressively accelerate drinking up to fifteen minutes before the

next meal. The patient should be urged to drink a lot of water in the

two hours or so before the following meal. This period of rehydration

ends with a " fluid load " fifteen minutes before the next meal.

However, a single pre-meal fluid load can never adequately rehydrate

an individual who has not already been drinking a lot of fluid. Fluid

loading can be done any time in the two to three hours preceding the

meal if hunger is experienced. This use of the fluid load can

substitute for taking in unwanted calories through snacking.

THE MANAGEMENT OF PATIENT TEACHING AND TRAINING

Postoperative patient instruction begins with setting appropriate

expectations preoperatively through the information provided in your

thorough patient information booklet. This is the time to introduce

fundamental principles such as: the small gastric pouch is a " tool "

to gain and maintain satiety. Most patients have a fairly clear

picture that a tool is something that one uses to perform a task but

that the tool itself is relatively useless if it is put away on a

shelf and not used. Patients also seem to appreciate that developing

skill in using a tool will make the tool more effective.

NECESSITY FOR LONG TERM FOLLOW-UP:

We emphasize the need for long term follow up care. It is not

possible in most patients to teach a fundamental change in lifestyle

in " theory " by written materials given preoperatively or immediately

postoperatively. The fine tuning of the teaching of how to use the

pouch/tool to prolong satiety is not probably able to be accomplished

until the patient redevelops hunger before the next meal, in the

sixth to twelfth month postoperatively. Techniques on delaying the

return of hunger are simply not relevant to most patients when they

are not hungry at all, as they are not in the first six months. Even

emphasizing preoperatively the crucial need for long term follow up

care does not always result in patients returning as they should, but

one must set the expectation for those who will be compliant for long

term follow up.

PREVENTION OF VOMITING

We believe strongly in the principle that vomiting should be

prevented if at all possible. This teaching begins in the hospital on

the second postoperative day when we initially instruct the patients

to drink only out of one ounce cups, and to drink only one-third of

that ounce at a time with sufficient time between thirds to detect

fullness. We emphasize that it is not easy to get used to having a

small pouch volume. For the first few months, the patient's mouth

will be larger than their stomach, a situation which otherwise does

not exist in the mammalian kingdom. Also, we keep our standard

gastric bypass patients with their small edematous outlet on liquid

feedings for the first six weeks, gradually advancing from totally

liquid nutrition such as

Ensure supplemented by protein powder up through a blenderized diet

and very soft solids. The banded gastroplasty/distal gastric bypass

procedure with its relatively generous 7.0 cm band on its outlet is

advanced more quickly to soft solid foods by three weeks.

Vomiting seldom occurs in the immediate postoperative period unless

there is an outlet obstruction problem. However, vomiting can occur

and will do so in most patients at some time after starting on solid

food. There are more complexities when eating solid food especially

rice, pasta, or granola, foods that swell in the stomach after being

eaten because they are generally incompletely rehydrated before being

consumed. The most frequent cause of vomiting is overloading the

pouch. We encourage patients to continue to measure their meals with

their one ounce cups for weeks, even months, following the surgery if

they are experiencing difficulty with vomiting. We emphasize

repeatedly that they should eat only until " comfortably satisfied " as

the word " full " has different meanings to different persons.

SIX WEEKS

Solid food is begun with emphasis on the fine cutting of fibrous food

to the size of the fifth fingernail or smaller, thoroughly chewing,

three or more foods at each meal to prevent wadding up of similar

fibers, eating only until " comfortably satisfied, " and beginning,

even at this early date, to teach the concept of no liquids with

meals for fifteen minutes before meals and for one and a half hours

after meals.

REASSURANCE OF ADEQUATE NUTRITION

Many patients need reassurance that they can achieve adequate

nutrition in the postoperative period. Without this reassurance, some

patients will deliberately eat six to eight times a day because of a

fear of malnutrition (often initiated by well meaning family members

and friends). We like to point out that in this short period of time

during the pouch growth, there are only two major nutritional needs:

protein on the one hand and vitamins and minerals on the other. The

latter can easily be achieved by the patients routine twice a day use

of the vitamin supplements. Therefore, their only responsibility and

focus is to eat low-fat, animal-source protein at each meal, three to

four times a day. If they do this or simply come close to doing this,

they will end their first year post-op with a lower than pre-op lean

body mass but one that is appropriate to their body weight at that

time.

(reference 4)

MEAL SKIPPING

On the other hand, some patients are likely to skip meals when they

have no appetite, similar to their behavior previously when their

appetite has been diminished by over tiredness or illness. We

emphasize the need for three to four meals a day, including

breakfast, primarily to meet their needs for protein. We emphasize

that one-half or more of each meal should be composed of this low-

fat, animal-source protein (two-thirds of their meal in the distal

gastric bypass procedures) in the first months until their pouch

volume is large enough so that they can eat at least two ounces of

protein at each meal.

ARTIFICIAL SWEETENERS:

We warn our patients to be aware of using artificial sweeteners if

they are experiencing hunger in this early p.o. period. We have

evaluated a few patients who experienced very strong hunger cravings

in the first weeks or months post-op whose hunger abruptly ceased

with stopping artificial sweeteners.

AVOIDING ABSOLUTES

There are so many rules that we teach concerning the use of

the " pouch/tool " that we believe that it is important to emphasize to

the patient that it is not necessary to follow every rule all of the

time. We actually suggest that it is perfectly all right to break the

rules once in a while- the important thing is to be aware that one is

breaking the rule and having a reason for it even if that reason is

simply alleviating frustration. We point out that the only penalty

for eating a liquidy meal when appetite has returned is the earlier

return of hunger in the next four to five hour period. There is no

lasting effect beyond that next meal. We also point out that deciding

to take advantage of a social opportunity to eat a high calorie,

empty calorie meal is the ingestion of a relatively insignificant 600

to 1,000 calories instead of the 3,000 to 5,000 calories that could

be consumed in such a meal with a normal stomach volume.

THREE MONTHS

At three months we step up the teaching of the nutritional or protein-

containing value of foods related to the " cost " of that protein food

in terms of calories consumed, i.e. a gram of cottage cheese

protein " costs " only five calories, but a gram of cheddar cheese

protein costs sixteen calories, and peanut butter twenty-four

calories. Water loading techniques (see below) are introduced at

three months postoperatively as some patients will begin to see a

return of appetite before their six month office visit. Overall fluid

management is discussed, emphasizing how the Gastric Emptying Test

illustrates the principles of fluid management (see below).

THREE PRINCIPLES FOR GAINING AND MAINTAINING SATIETY

1. The pouch needs to be truly filled with adequate wall distention

with each meal (i.e. no snacking).

2. Keep the pouch filled over time and slow down the emptying time

(by eating solid foods and avoiding liquids for fifteen minutes

before and one and one half to two hours after eating. We understand

this to be the most important lifestyle change after the gastric

bypass procedure. Figure 3 shows the results of a standard gastric

emptying test using radioactive sulfur with a scrambled egg, bread,

and milk. With the milk, 90% of the meal volume has exited the

stomach within forty-five minutes. However, without the milk, only

45% of the meal has exited the stomach by ninety minutes.

3. Finally, adequate protein with each meal. We emphasize three meals

a day including breakfast (defined as the first meal of the day which

is eaten within one to two hours after arising). We define

the " enemy " as high calorie liquids. We point out that snacking and

high calorie liquids cheat the patient because the calories are taken

in without offering significant satiety.

FLUID LOADING

Fluid loading is the rapid drinking of a non-calorie or low-calorie

liquid on an empty stomach in order to achieve a maximal intake of

water at that time and/or achieve immediate satiety which lasts for

fifteen to twenty-five minutes. About 80% of the estimated maximum

capacity at any given time should be drunk rapidly over fifteen to

thirty seconds and then topped off with swallows until full satiety

is reached. Patients rather rapidly determine what their capacity is,

and it usually is between eight to twelve ounces when the Cottage

Cheese Test volume is four to six ounces. The fluids should not be so

cold as to be uncomfortable, but it is not necessary to be warm. The

mechanism of action is presumed to be the distention of the Roux limb

with subsequent contraction, stopping the progression of fluid

downwards and backing up the volume and pressure into the small pouch

and, perhaps, even into the distal esophagus. Fluid loading works

with the banded gastroplasty as well but not quite as effectively.

The mechanism here is probably primary distention of the pouch with a

fluid as it is passing through. The volume required is usually

somewhat greater, but it still is far less than two to four glasses

of water required in a normal sized stomach. Clearly, this small

proximal pouch is quite sensitive to distention, and the satiety

gained from that distention lasts far longer than the distention

itself. We teach patients to fluid load before each meal in order to

help prevent post meal thirst, but also to fluid load whenever they

feel the sensation of hunger and are tempted to snack.

POST PRANDIAL THIRST:

It is important that the patient be fully hydrated before coming to

the next meal because the solute load of the meal will create

postprandial thirst. It seems intuitive that persons cannot tolerate

thirst any more than they can tolerate hunger over the long run as

both hunger and thirst are primary noxious stimuli. Initially, when

the functional pouch volume is quite small, the solute load is

correspondingly small, and the patient may not see the point of

adequate rehydration and pre-meal fluid loading. However, as the

pouch volume increases and the solute load increases, it becomes a

significant issue in maintaining that important proscription of

avoiding liquids during and for an hour and a half after the meal.

URGENCY

In these first months we like to emphasize to patients that their

golden opportunity for maximizing their weight loss is in the first

six months after surgery. We illustrate this with the weight loss

curve, with its rapid downward sweep, with two-thirds of their weight

being lost in the first six months postoperatively. The Cottage

Cheese Test shows that two-thirds of the pouch growth occurs in the

first six months. Therefore, we teach our patients that every day

during this early period the exercise and activity that they do will

be more effective in burning calories in excess of their calorie

intake than the same amount of activity/exercise the following

day. . . and a little less effective than the previous day based on

progressive pouch growth. I.e. every single day the patient should

take advantage of their present opportunity and get as much activity

as they can, knowing that never again will that same amount of

activity result in as much weight loss. We try to give them a sense

of urgency about getting the most out of every day.

SIX MONTHS

At this point, or soon after, our patients are beginning to get

hungry before their next meal, and we accelerate the teaching of

satiety mechanisms and the prevention of post meal thirst. As the

meal solute volume increases, they need to push enough fluids in the

two to three hours before the meal to gain good hydration with final

water loading fifteen minutes before the next meal.

INTAKE INFORMATION SHEET AS A TEACHING TOOL

At each visit from three months to two years, the patient is asked to

complete a form before they come into the office. The form queries

them about their performance on the principles of pouch use (as well

as vitamin usage, exercise, pathological symptoms, etc.). This form

is designed so that it is also a teaching tool- each question reminds

the patient about the principles of the use of their pouch/tool.

Many, if not most, patients do very well, and their weight loss is

progressive and satisfying. Some struggle to make the lifestyle

changes necessary, but with these periods of intermittent monitoring,

encouragement, and teaching they progressively learn and most do

well. A few patients never seem to understand or to remember these

simple principles even though they might be quite intelligent,

capable persons in other facets of their lives. . .

HONEYMOON SYNDROME

The profound satiety that patients experience in the first six

months, along with the rapid weight loss due to intake restriction,

can lead certain patients to believing that these circumstances will

never change in spite of the clear teaching of our patient

information booklet and clinic visit handouts. For these patients, we

will then see a slackening off on their food selection and liquid

calorie control and see them indulge in more recreational eating.

They will cut back on their exercise as they seem to be losing a

great deal of weight without exercising. Their weight loss will

subsequently slow. We have dubbed this situation the " honeymoon

syndrome " and tried to educate our patients, even in our preoperative

informational booklet, that they can expect this temptation to occur

and that they must not get " suckered " into a false sense of comfort

that leads them to not make a sufficient effort in their own behalf

and miss this golden opportunity for weight loss. We have found that

an effective tool for identifying and reality-orienting the patient

is to graphically compare that patient's weight with the mean weight

loss of the group as a whole. Whatever the patients beginning weight

is, we would expect them to parallel the weight loss curve. If their

weight deviates from the expected, we should be able to find a reason

for it and to correct it if the patient is willing to learn and make

this needed lifestyle change.

EXERCISE

Although this chapter is about understanding the function of the

small proximal gastric pouch and how it relates to patient

management, a word must be mentioned about exercise. We believe that

the scientific data overwhelmingly demonstrates that 1) exercise is a

critical part of a healthy lifestyle for patient and doctor alike,

and 2) that exercise is necessary to maintain weight loss in the

obese patient. Therefore we believe it must be a critical part of our

postoperative patient teaching and encouragement. Exact details are

beyond the scope of this presentation, but we do emphasize to the

patients that the feelings of vigor and energy are in no way

guaranteed by a slender figure. Observations of people on any city

street confirm this. . . We emphasize that the release of endorphins

with aerobic exercise improves emotional stability and mental clarity

and helps any person to cope with the deprivations and annoyances of

everyday life. Endorphins, adrenalin, norepinephrine, etc., also act

in an antidepressive manner. But most importantly, especially in the

first six month period when the gastric pouch is so small, regular

aerobic exercise maintains, or even improves basal metabolic rate

that is observed to drop during rapid weight loss.

THE IDEAL MEAL FOR WEIGHT LOSS

The ideal meal for weight loss is one-half of the meal volume up to a

total volume of two to three ounces of animal-source, low-fat protein

plus filling the rest of the pouch volume with low starch vegetables

and solid type fruits such as apples and pears. Cut finely and chewed

well, these foods represent coarse, solid food choices that are

likely to stay in the pouch longer and offer good nutritional value.

VOLUME VERSUS CALORIES

A person with a normal stomach tends to judge how much he/she needs

to eat at a given meal by approximately how many calories are in that

meal (although not necessarily thinking of calories as such). In

other words, we know that we are going to be unpleasantly hungry

before dinner if our noon meal consists of a green salad and a couple

of ounces of cottage cheese. Calories are what keep us from getting

hungry between meals. On the other hand, the post-op gastric bypass

patient needs to learn to think about the volume and consistency of

food choices rather than their caloric content when judging how to

prevent getting hungry before the next meal. I recall a lecture I

once attended in which the lecturer pointed out that one or two

sticks of butter could meet our entire calorie needs for the day and

could be easily consumed by even the small post-op gastric bypass

pouch. However, that same number of calories in the form of non-

starchy raw vegetables could not be consumed by a person with a

normal stomach in only three meals a day. There is an enormous

variation between calories and volume, and a patient needs to learn

how to " think volume " when making food choices to gain and maintain

satiety in a mature small gastric pouch.

ISSUES FOR LONG TERM WEIGHT MAINTENANCE

The previous comments are primarily designed to deal with patient

issues in the first year following a gastric bypass procedure. These

issues should seamlessly slide into long term weight maintenance and,

indeed they do so in most persons.

COUNTER-INTUITIVENESS OF FLUID MANAGEMENT:

It is clear that avoiding liquids with meals and pushing fluids

between meals is counter intuitive. The large capacitance of a normal

stomach is a great convenience factor for that person and, truly, all

animal life. There is a resistance to learning this technique, and

clearly it is counter intuitive to the experience of the individual.

However, if it is important that solid food be taken rather than

liquidy food to maintain satiety, then it is clearly important to

avoid liquids with meals or soon after meals as the liquid will

simply make the food more soup-like and soft and allow more rapid

emptying of the pouch and, therefore, shorten the period of satiety.

SUPPORT GROUPS

We have found that support groups are very effective in reinforcing

the principles of the pouch/tool use. Many, if not most, patients

will explore these principles on their own by using them and then for

a time not using them. Some patients on their own become convinced of

the value of these principles through this natural experimentation.

However, others may lose their way. The support group offers an

excellent feedback mechanism for individuals who need reinforcement

of the principles of the pouch use. Sometimes, the feedback of their

peers is more effective than that of the parental figures in the

surgeon's office.

TEETER-TOTTER EFFECT

One " visual " that we use when discussing weight maintenance is that

of a teeter-totter. On one end of the teeter-totter is the

exercise/physical activities, and on the other end is the meal choice

discipline and fluid restrictions. When one has a large amount of

exercise and activities, the teeter-totter swings down on that end,

and the amount of effort that need be placed on diet discipline

lightens up. When one is light on the activity/exercise, one has to

be much heavier on the diet discipline side. If one is light on both

exercise and diet discipline, the whole teeter-totter moves upward as

weight is gained. On the other hand, if one is " heavy " on both

exercise and diet discipline, the teeter-totter bar goes down, and

weight is lost.

TOO MUCH WEIGHT LOSS

There are a group of patients in our practice, approaching 15%, who

lose too much weight in the one to two year period postoperatively.

Inevitably, these individuals were only 100 to 150 pounds overweight

to start with and are good exercisers. We encouraged them to taper

off their efforts with diet discipline (maintaining their exercise

routine and thus their vigor) by adding some fat back to their meals

and eating a fourth or fifth meal a day with less discipline on the

fluid management. Basically, it is an exercise on " how to beat the

pouch. " The pouch can be beaten by one, liquid high calorie meals;

two, frequent meals or grazing; three, eating a meal over thirty to

forty-five minutes; four, adding liquid to meals to enhance gastric

emptying; five, liquids are taken shortly after eating which

increases gastric emptying and decreases the satiety period. Some

patients take our advice and taper off their weight loss before they

go underweight. However, a small but significant group of patients

actually go underweight because all of our patients have experienced

the rapid and frightening return of severe hunger cravings when going

from one of their many diets to trying to eat normally once again.

Very similar to a bear coming out of hibernation, their suppressed

appetite center seems to burst out with vigor in order to save the

life of this person who the appetite center sees as a normal weight

person having suffered in a famine. Many patients at this point have

not yet fully accepted that they have had a true anatomic and

physiologic change from their operation and that, using the

principles of the pouch/tool, a return of this overwhelming appetite

will not occur. For these persons, it is not until their lean body

mass is effected and they lose their delightful sense of vigor that

they will begin to " break the rules " and gain some needed weight

back. This is probably the primary reason why, in most bariatric

surgical practices, the weight loss curve bottoms out at eighteen to

twenty-four months with a rise at two to three years. This rise has

been erroneously interpreted as most patients regaining 10% to 15% of

weight from the nadir of their weight loss.

BARIATRIC MEDICINE

A much more common problem is that of patients who have not lost as

much weight as they would like and are plateauing at a level above

their goal weight. Bariatric medicine techniques can be useful in

helping our postoperative patients who find themselves stuck on a

plateau one or more years postoperatively. However, there can be a

problem with standard weight control and dietary teaching of

Bariatric medicine. The frequently used recommendations of frequent

small feedings or liquid calorie fasts such as a protein sparing

modified fast, neutralizes the satiety function of the pouch/tool,

and tends to negate the teachings of the principles of the pouch use,

and therefore is probably not an optimum way of managing the patient.

SUMMARY

The principles of the postoperative bariatric surgical follow up

management are as follows:

1. Understanding the fundamentals of the anatomy and physiology of

the pouch/tool.

2. Evaluating the patient's appropriate or inappropriate use of the

tool- What is lacking? What is being done well?

3. Instruct patient with words, drawings, analogies, encouragement,

and passion, on not only what to do but why it needs to be done.

The goal is to make the patient become fully knowledgeable about how

to control their own weight over the long term through the

appropriate use of their pouch/tool, combined with a reasonable

amount of exercise.

EVALUATION FOR WEIGHT LOSS FAILURE

Evaluating a patient who is progressively regaining weight can be

relatively simple- or extremely difficult. The first principle is to

determine that the gastric pouch is anatomically intact. If it is not

intact, it should be made intact by a revision procedure. Only when

the surgeon can be reassured that the pouch is intact does the

complex part begin- evaluating how and why the patient is not using

the pouch/tool properly, and/or getting a reasonable amount of

exercise.

We need to know three things about the small gastric pouch. First, is

the staple line intact; second, is the outlet intact; and third, is

the pouch reasonably small in size.

The upper GI series with thick barium is the basic tool for

evaluating intactness of the staple line and the outlet. If the pouch

has been stapled in continuity with the rest of the stomach, we must

confirm that the staple line remains intact. An eventration of the

staple line will create two gastric outlets leading to rapid pouch

emptying, early loss of satiety, and thus early return of hunger. An

important clue from the patient's history is the presence of a

marginal ulcer after a gastric bypass. Marginal ulcers do occur,

occasionally, with an intact staple line. However, they are more

common with a small hole in the staple line that results in food

stimulation of the antrum. If there is a staple line eventration, the

marginal ulcer is unlikely to be able to be controlled without

reoperation and closure of that eventration, preferably with complete

division of the small pouch from the distal stomach.

The upper GI series with thick barium in the hands of an experienced

radiographer can usually give the bariatric surgeon a reliable view

of the diameter of the gastric outlet. A diameter of over 18-20

millimeters is usually associated with weight regain, and we term

this " outlet failure. " Outlet failure, like a staple line

eventration, causes rapid emptying of the pouch, early loss of

satiety, and early return of hunger.

On the other hand, weight regain can occur as a result of an outlet

diameter under 7-8 millimeters which can lead to persistent vomiting

of solid foods and gradual persuasion of the patient towards the Soft

Calorie Syndrome with resultant rapid pouch emptying, early loss of

satiety, early return of hunger, and weight regain.

The upper GI series is less effective for evaluating pouch volume

because of the fact that barium is very much of a liquid. To assess

pouch volume, you must turn to the patient's history of the size of

the meal that he/she can consume within a short five to fifteen

minute time frame, and/or to the Cottage Cheese Test (see above).

In the patient whose gastric pouch seems to be anatomically intact

and yet he/she is still regaining weight, the evaluation becomes more

complex. The usual finding is that the patient is not following the

principles of the use of their pouch/tool and/or is extremely

inactive physically. There are four problems that occur with some

frequency: the patient has never been taught/or does not understand

how to use the tool; the patient is significantly depressed; or loss

of contact with a bariatric practice and other bariatric patients and

a gradual erosion of following the principles; or the patient is

truly noncompliant and will not take responsibility for his/her own

behavior.

LACK OF TEACHING

An excellent example of the lack of teaching/understanding of how the

pouch works is found in the history of GC. GC is a 62-year-old woman

who presented in consultation for a total regain of her weight and

complaint of constant hunger, sixteen years following a gastric

bypass procedure in Cambridge, Massachusetts. She stated that she had

not seen the surgeon beyond the six week follow up visit. She

understood nothing about how to use her gastric pouch. She initially

lost fifty pounds and then another forty pounds further with the help

of a commercial weight management program. For the next ten years she

yo-yoed up and down with the usual peer group and doctor supported

programs with a gradual increase in weight and the usual hunger and

deprivation syndromes relating to these programs. She then developed

myasthenia gravis and her weight regain escalated to her preoperative

weight, resulting in the referral. At the time of the referral she

was being treated effectively for myasthenia gravis and was

reasonably active, being able to walk over a mile at a time. Her

weight loss curve with its abrupt turn around and rapid weight loss

(figure 4) could be consistent with a revision reoperation. However,

there was no revision done. After evaluation of her pouch/tool with

an upper GI series and a Cottage Cheese Test/functional meal volume

estimation, she was given the basic instructions of how to use her

pouch/tool, the same given to all of our postoperative patients. Her

ensuing and continuing weight loss is impressive, but more impressive

to the patient is that she is not experiencing any distressing hunger

cravings, food fantasies, or food dreams as she had experienced with

all of her previous efforts, since the first months after her gastric

bypass procedure sixteen years ago.

DEPRESSION

Depression is a powerful inhibiter of success after bariatric

surgical procedures. A small but significant number of our patients

have been doing well following their gastric bypass procedure only to

drop out of sight for a time and then reappear with a significant

weight regain. Upon evaluating these patients, it would appear that

in many instances they seemingly deliberately reverse all of their

learned principles of the use of their pouch/tool: grazing and

snacking through much of the day, drinking high calorie liquids,

drinking liquids with meals, and stopping their exercise, even when

they are intellectually aware that exercise in itself releases

numerous vasoactive substances which act like antidepressants. DB is

a 46-year-old woman who had an excellent initial weight loss

following a gastric bypass procedure (figure 5). While still in the

first year after her gastric bypass, her life, already made difficult

by divorce and economic circumstances, became severely disrupted when

her only daughter developed a drug problem, an abusive relationship,

and finally HIV, and was forced to give up her newborn child. Her

weight regain was dramatic. However, even more dramatic was her

weight loss once her depression eased, and she was able to look after

herself once again. She relates that she did nothing dramatic such as

fasting. She simply returned to using her pouch/tool in the manner in

which she had been taught and resumed a moderate exercise program.

What can the bariatric surgeon do when patients are obviously

depressed and regaining weight? Obviously, the most important thing

is to steer them to professional counseling, if they are not already

in counseling. Then, the surgeon can be encouraging. We can encourage

them to continue to use the tool as best as they can; we can

encourage them to return to exercise which will improve the spirits

and reassure them that the improvement is " deserved, " " because you

really are a good person, and you deserve to feel better. . . " Most

of all, the surgeon can reassure them that the pouch/tool is not

ruined by this overeating and gradual weight regain if it does not

result in persistent vomiting of solids. When they are ready once

again to use their pouch/tool, it will be there for them, and they

will be able to once again lose weight without being hungry.

EROSION OF THE USE OF THE PRINCIPLES:

In a third subset of weight maintenance failure patients, a subtle

weight creep can occur to patients who are otherwise compliant, non-

depressed, and have intact pouches. The patient will see it

as " struggling " with his/her weight, and by definition, he/she will

not have seen you in follow up and will have usually lost contact

with the support group or other bariatric surgical patients. There

seems to be a progressive erosion of following the principles of the

pouch/tool use. This may be due to denial as seen in diabetic

patients, or it may be due to the influence of their peer group and

the fact that some of the principles of the use of the pouch/tool,

especially fluid management, are counter- intuitive and counter to

behavior of their peer group. The patient will often not come back

for evaluation because " I know what I'm doing wrong! " (meaning that

he/she is eating the wrong things and too often), and these patients

will internalize their " failure " with an increasing sense of guilt

which itself acts as an inhibition to coming back to their surgeon's

office for help.

From the beginning, in our preoperative teaching, we emphasize the

possible need for a " refresher course " in the use of the principles

of the pouch/tool at some time in the future. Some patients still do

not return. The trick is identifying these patients and somehow

getting them back either into the office or into a support group.

In these three examples- lack of teaching, depression, and gradual

erosion of the use of their tool, weight once regained can be lost

once again if the pouch is anatomically intact and the patient

decides to use it, or learns how to use it or relearns how to use it.

In these three examples, we are working with compliant, reasonably

responsible persons who, when they can, are willing to take

responsibility for their own behavior.

TRUE NON COMPLIANCE:

The most difficult problem is determining, and being comfortable with

that determination, when a patient is being fundamentally

noncompliant and obstructive. This type of individual may leave your

care and go to others complaining about a " personality conflict, " or

perhaps even that you have not given them the time and attention that

they need and deserve. Inexplicably, some will actually stay in your

care. In this instance, when the patient tends to return perhaps even

more frequently than usual, depression will be more likely the

underlying mechanism rather than noncompliance. It can be difficult

to be reasonably sure of what is going on in one or two visits. The

truly noncompliant patient will very likely end up with multiple

revisions and/or a reversal due to weight regain or complications.

This kind of patient is often quite resistant to counseling, but I

know of no other management option that offers much hope for success.

Luckily, this type of patient represents a very small minority of our

patients. Obviously, prevention in the form of patient selection is

better than cure, but after twenty-three years of a bariatric

surgical practice, I have yet to be able to effectively identify

these persons preoperatively. I have, in fact, suspected significant

noncompliance in a number of my patients who have turned out to be

quite compliant particularly after control of other problems, such as

sleep apnea, that effect understanding and complying with our

instructions. With the current lack of an effective psychological

screening tool to reliably identify these individuals, I tend to lean

towards giving each person a chance at a good and healthy life

provided by bariatric surgery.

BIBLIOGRAPHY

1) Mason, EE, Personal Communication, 1980

2) Barber, W, Diet al, Brain Stem Response To Phasic Gastric

Distention. Am J. Physiol 1983; 245(2): G242-8

3) Flanagan, L. Measurement of Functional Pouch Volume Following the

Gastric Bypass Procedure. Ob Surg 1996; 6:38-43

4) Rosemurgy, A.

[Guest guest]

Hi,

I don't drink hardly enough!! I need to INCREASE my fluids! I know that will

change with my new job, but it is hard for me to find a drink that I really love

and can drink alot of. I really like iced tea, but have cut down dramatically.

I made some homemade lemonade which is ok, but not really all that refreshing...

I'll stumble on something one of these days.

aW

MGB 5/28/00

214/115ish

Re: Drinking/thirsty

> This is good information and we would all do well to study it. I am

immediately going to implement the hydration suggestions and the info about

the solids in the meals. It makes sense, and I am immensely heartened to

read about correcting weight problems years later with following the correct

use of our " tool. "

>

> Thanks so much for finding and sharing this article.

>

> Pat

[Guest guest]

---

What a great article... I have been putting some of those principles

to use and have broken my plateau and lost 4lbs YAY I am eating

much more protien, and really working on fluid loading and the

hardest ting is working on drinking BEFORE MEALS... I was drinking

with meals, not much, but some, and now I won't be doing that any

more.. I found especially interesting the part where the woman had

regained her weight over the 16 years and by using these principles

was able to lose weight again, since according to thise article I am

done with the honeymoon stage, which I had already figured out..and

the larger amounts of protien makes me feel full longer and works

well.This article should be part of the clos.net site for all post-

ops it really stresses proper managment of the " tool " .

Suzanne

1.10.01

-64

In @y..., " wwmohler " <wwmohler@s...> wrote:

> Here is an article that might shed some light on the drinking etc.

with meals along with some other information. Now although it was

not written by our beloved Dr. R, (Dr. R feel free to chime in, maybe

he even knows the Dr. that wrote this,) there is some information I

have found useful.

>

> POST-OP TEACHING AND EVALUATION

>

> By Latham Flanagan, Jr., M.D., FACS

>

> Article is sectioned by capitalized categories.

>

> INTRODUCTION

>

> >From our earliest experiences in bariatric surgery, we have been

> intrigued with the question " How does our operation cause weight

loss

> and maintenance? " As we talked to the public, and even our medical

> peers, it became evident that a common concept of the uninformed is

> that the small gastric pouch simply mechanically restricts intake,

> preventing the post-op patient from eating too much. Indeed,

> superficially, it may appear that way especially in the first 3-9

> months post-op. However, even a short experience with following our

> patients shows us that with a meal size of even three to five

ounces,

> certain patients will stop losing weight and start to regain. We

also

> note that two to five or more years postoperatively certain

patients

> seem to have a large meal volume of six to ten ounces but still

> maintain good weight control without an noxious degree of hunger.

It

> has become clear with experience that the principle of weight

control

> is the achievement of satiety, or the absence of abnormal hunger,

> associated with the ingestion of the appropriate number of calories

> sufficient to meet the person's need. If adequate satiety is

> achieved, our patients are successful. . . And they fail if that

> satiety is not achieved. When patients " fail " there is a tendency,

> even among bariatric surgeons, to pass it off as " noncompliance. "

> Certainly, this can be an appropriate evaluation in a few persons

who

> are not willing to accept responsibility for the lifestyle changes

> necessary to make the small gastric pouch function properly. But,

is

> this the problem for the majority? I think not. When failure does

> occur, it is usually the inability to maintain the post meal

satiety

> long enough to prevent snacking before the next meal time arrives.

> Also, it could be due to ingestion of a large number of calories in

a

> form that is somewhat hidden to the patient and is not responsive

to

> the gastric pouch restriction, especially high calorie liquids.

>

> HYPOTHESES OF POUCH FUNCTION:

>

> At this point in time what have we learned about how the small

> gastric pouch works? In the form of an hypothesis, we can now state

> that the basic mechanism is that of stretch of the pouch walls with

> eating of a small meal, or even the drinking of fluid. This stretch

> is sensed by the stretch receptors in the pouch wall and relayed by

> neural pathways to the appetite centers in the hypothalamus by way

of

> the tractus and nucleus solitarius. The second hypothesis is that

> successful maintenance of satiety depends upon the creation and

> maintenance of a small gastric pouch and a small gastric pouch

outlet

> (Mason- reference 1). The third hypothesis is that the observed

> increase in functional meal volume over the months and years

> following a gastric bypass procedure is due to the process of

> hyperplasia and is not wholly or in great part due to noncompliance

> on the part of the patient. The fourth hypothesis is that

> understanding of these principles and effective teaching to a

> compliant patient results in better weight loss and maintenance

than

> if the teaching is not accomplished.

>

> PUBLISHED DATA

>

> To support these four hypotheses, we have two pieces of reasonably

> good scientific information from peer reviewed published articles.

> From that point we must rely on observational-based science.

>

> Our first question is how does the small gastric pouch create

> satiety? Considerable insight on the neurological pathways of

satiety

> has been obtained through the work of Barber, a Ph.D.

> veterinarian, and his associates who published a paper in 1983

> entitled " Brain Stem Response to Phasic Gastric Distention. "

> (reference 2) They placed a balloon in the stomachs of anesthetized

> cats and surrounded the stomach with a strain gauge.

Microelectrodes

> were placed in the nucleus and tractus solitarius of the brain

stem.

> They found a population of neurons that faithfully monitor moment

to

> moment changes in gastric wall tension. The discharge frequency to

> wall tension did not adapt for the twelve hour period of the

> experiment. This response was dependent upon an intact vagal nerve

in

> these cats. They concluded that " these neurons may serve as a

> critical link between the stomach and higher centers in the

conscious

> perceptions of fullness. " It seems particularly impressive and

> interesting that the neurons continued to fire at an accelerated

rate

> for as long as twelve hours, if the gastric wall tension remained

> high.

>

> Another question of considerable importance to the thinking of a

> bariatric surgeon is what is the fate of the small gastric pouch?

> Does it enlarge at all after the surgical procedure? If it does

> enlarge, is it because the operation was done improperly? Was it

> because of gross patient noncompliance and gorging? Or, is it due

to

> the kind of hyperplasia seen throughout the gastrointestinal tract,

a

> response to loss of function? Dr. E. E. Mason, at one of the Iowa

> Bariatric Symposia in the early 1980's, suggested that it might be

> useful to ask patients to eat cottage cheese in a structured manner

> in order to attempt to determine their functional meal volume at

> different times postoperatively. I took the idea home and began

> asking all of my patients to do this simple test with each one of

> their follow-up postoperative visits at three, six, nine, twelve,

> eighteen, and twenty-four months. We continued to do this over the

> next decade (and subsequently to date), and figure 1 reveals a

> regular, progressive, stepwise increase in functional pouch volume

> over time that strongly suggests the orderly process of

hyperplasia.

> Stabilization occurred at two years at a mean pouch size of six

> ounces with a wide range of three to nine-ten ounces. The pouch

> appears to not get larger after the second year. (reference 3)

These

> gastric bypass pouches were created as a vertically oriented, 30 cc

> pouch measured against both volume and pressure of 70 to 85 cm of

> water. The curve of pouch enlargement is the inverse of the weight

> loss curve.

>

> We then proceeded to compare the patients' weight losses at one and

> three years to pouch sizes at one year. Figure two reveals that

there

> was no difference in percent excess weight loss at one year, with

the

> different pouch sizes within this range of up to nine-ten ounces.

We

> then compared the largest third of pouch sizes to the smallest

third

> of pouch sizes, and still there was no significant difference in

> weight loss at one year or of maintenance at three years. This

> finding is, perhaps, the most important result to come from the

> Cottage Cheese Test work. It strongly suggests that within these

> limits of pouch sizes that success in weight loss and maintenance

> depends not only on having a small gastric pouch but even more so

in

> how the patient uses their " pouch/tool. " If this is true, then the

> implication is clear that learning how to use the pouch/tool

> effectively is important and that it is our responsibility as

> bariatric surgeons to see that effective teaching is made available

> to our patients over this two year period of changing intake and

> satiety control. In brief, the Cottage Cheese Test data tells us

that

> within the context of a small meal volume, lifestyle change

including

> exercise is the most important variable. The stepwise progressive

> growth in the functional pouch volume (meal size) probably defines

> the rate of weight loss for the patients taken as a whole, but the

> degree of weight loss and maintenance for the individual patient is

> more dependent upon that patient's ability to make the required

> lifestyle changes: proper use of the pouch/tool and adequate

amounts

> of activity and exercise.

>

> OBSERVATIONAL-BASED MEDICINE

>

> Observational-based medicine has a long history of respect going

back

> to the early work of two of my personal surgical heros, s

> Vesalius and Ambrose Paré. Indeed, we often refer to the " art and

> craft of surgery " . Although we do make great effort to have a

> scientific basis to our surgical decision making, ideally with

> prospective randomized studies or double blinded studies, at this

> point in time the majority of what we do is based on empiricism, or

> observational-based medicine. The observations that I would now

like

> to share from my own personal thirty-three years of experience in

> bariatric surgery are also shared by many other experienced

bariatric

> surgeons of my acquaintance, although not all would agree with all

of

> these principles.

>

> For the first fifteen years, although I remained busy in a general

> surgical practice, my primary interest, bariatric surgery, lagged

> because of the lack of patient material, primarily because of the

> profound discrimination of medical insurers against the morbidly

> obese in our area of the country. What appeared to be a

disadvantage

> initially became an advantage, as I thereby had the opportunity to

> follow almost all of my patients personally during that time. As

> there was little known about the mechanism of action of the gastric

> bypass procedure, I spent a good deal of my time thinking about

> possible mechanisms and observing the differences between patients

> with good weight loss and those with poor weight loss. Since the

> beginning, I have performed the short limb gastric bypass procedure

> (GBP), only adding the malabsorption procedure of the banded

> gastroplasty/distal gastric bypass procedure (BG/DGB) in 1992. The

> BG/DGB also uses a small, vertically oriented gastric pouch quite

> similar to the gastric bypass procedure pouch, the difference being

> that the outlet is controlled by a band as in the vertical banded

> gastroplasty and silicone ring gastroplasty, etc., instead of a

> gastroenteric anastomosis. My observations seemed to be similar for

> the two procedures, although not identical for both. The Cottage

> Cheese Test was done only with the GBP. Considering the above, what

> do I think that I have learned?

>

> The following are observations that may have an effect on the

> function of the gastric bypass pouch:

>

> 1. We have come to understand that the accomplishment of satiety,

or

> suppression of hunger, is fundamental to the success or failure of

> bariatric operations.

> 2. We have come to understand that success relates anatomically to

> creating a small pouch that remains relatively small and a small

> outlet that remains relatively small (Mason).

> 3. Meal volumes much larger than ten-twelve ounces usually result

in

> failure of weight maintenance.

> 4. The use of the thick, less distensible lesser curve of the

stomach

> is believed to be important by many surgeons.

> 5. Satiety is achieved by increasing the tension on the gastric

pouch

> wall, thus stimulating the stretch receptors.

> 6. Maintaining satiety is dependent upon maintaining some portion

of

> that stretch for an undefined period of time.

> 7. For either the gastric bypass or the banded gastroplasty, almost

> all patients have a profound satiety, 24 hours a day, in the first

> six months or so following their bariatric surgical procedure. They

> do not redevelop a normal appetite preceding the next meal until

six

> to twelve months postoperatively.

> 8. If for any reason the patient is NPO for a significant period of

> time like eight to twelve hours, a profound hunger will be

> experienced.

> 9. In the mature pouch at one plus years post-op, the more solid of

> food that a patient eats, the longer is the satiety period after

the

> meal.

> 10. Almost all patients after the gastric bypass procedure, and

most

> patients after the vertical banded gastroplasty, achieve fifteen to

> twenty-five minutes of satiety after simply rapidly drinking water

to

> a point of fullness, or " water loading. "

> 11. Some patients fail the banded gastroplasties in association

with

> shifting their diets to mostly liquids or soft solids, the " soft

> calorie syndrome, " and they fail by becoming hungry too soon before

> their next meal and giving in to snacking between meals because of

> that hunger.

> 12. Responsible patients who carefully follow the principles of

using

> their " pouch/tool " continue to have a reliable and progressive

weight

> loss and weight maintenance.

> 13. Patients who approach or become underweight at one to two years

> following bariatric surgery can reverse their weight loss with

> reversing the principles of using their pouch/tool.

>

> HOW DO WE INTERPRET THESE OBSERVATIONS?

>

> POUCH SIZE:

>

> It seems intuitive that the functional meal volume must stay small

in

> order to limit the patient's caloric intake and provide satiety.

What

> is not clear is how small it must remain. The Cottage Cheese Test,

> discussed previously, gives us some insight. With the data from

that

> test, the pouch size/functional pouch volume can exceed six to

seven

> ounces and still give as good a satiety as a smaller pouch.

> Obviously, this depends on patient behavior such as choices of

> specific foods eaten, frequency of meals, fluid management, and

last

> but certainly not least, the amount of activity/exercise.

>

> OUTLET SIZE:

>

> The outlet of the small gastric pouch is a fixed ring, either fixed

> by scar or fixed by a band or both. There is no longer a valve that

> controls the rate of emptying. Therefore, it is intuitive that

> liquidy foods will exit the pouch faster than more solid foods.

> Certainly, no pouch can control the amount of fluid consumed, nor

> would it be tolerable if that could be done. Therefore, the

calories

> contained in high calorie liquids have the ability to defeat weight

> loss or maintenance.

>

> EARLY PROFOUND SATIETY:

>

> The mechanism of action of the profound satiety of the first six

> months is presumed to be due to the necessity of the patient

drinking

> water very frequently throughout the day in order to meet minimal

> fluid requirements. From our experience with " water loading, " we

note

> that water loading will give almost all patients fifteen to twenty-

> five minutes of satiety if done when they are hungry. Presumably,

the

> frequency of water drinking during the first six months simply

> overlaps these short periods of water-induced satiety.

> The return of appetite in our patients at about six months

correlates

> with two-thirds of the pouch hyperplasia as determined by the

Cottage

> Cheese Test. The average pouch size then is approximately four

ounces

> when the lesser curve pouch is created at one ounce in volume at 70-

> 85 cm of water pressure. The mechanism of action is presumed to be

a

> less frequent stimulation of stretch receptors in the gastric pouch

> wall because at this point the patient can ordinarily drink six to

> eight ounces of water at a time.

>

> OPTIMUM MATURE POUCH:

>

> How might we describe the optimum mature pouch? The pouch seems to

> work best when one, the outlet is not too restrictive to allow

eating

> of solid foods such as meat and vegetables but two, the outlet is

not

> so large as to allow early emptying and premature loss of satiety

> from solid food, and three, the pouch is not too large to allow

over

> eight-nine ounces a meal.

>

> IDEAL MEAL PROCESS:

>

> What might be the ideal meal process? The ideal meal process

includes

> timing of meals. To get through the day without hunger on three

meals

> a day, there needs to be about five hours between breakfast and

> lunch, lunch and dinner, and dinner and bedtime. It becomes evident

> that if there are only three hours between breakfast and lunch, and

> then six to seven hours between lunch and dinner, that one cannot

> expect satiety to be maintained over the full seven hours, no

matter

> how solid the food eaten, short of frank outlet obstruction. For

the

> optimum meal, a more solid type of food such as finely cut meat and

> minimally cooked or raw vegetables should be eaten. The meal should

> be taken over five to fifteen minutes, depending upon the

functional

> pouch volume. Stringing a meal out over thirty to forty-five

minutes

> or more is one of the techniques that has been used to " beat the

> pouch. " Following the meal, take no liquids for one and a half

hours,

> or even two hours if satiety is lost too soon before the next meal.

> Then, after that one and a half to two hours is up, begin drinking

> low or no calorie fluids somewhat slowly (in order to avoid over

load

> symptoms if there is still considerable food in the pouch) and then

> progressively accelerate drinking up to fifteen minutes before the

> next meal. The patient should be urged to drink a lot of water in

the

> two hours or so before the following meal. This period of

rehydration

> ends with a " fluid load " fifteen minutes before the next meal.

> However, a single pre-meal fluid load can never adequately

rehydrate

> an individual who has not already been drinking a lot of fluid.

Fluid

> loading can be done any time in the two to three hours preceding

the

> meal if hunger is experienced. This use of the fluid load can

> substitute for taking in unwanted calories through snacking.

>

>

>

> THE MANAGEMENT OF PATIENT TEACHING AND TRAINING

>

> Postoperative patient instruction begins with setting appropriate

> expectations preoperatively through the information provided in

your

> thorough patient information booklet. This is the time to introduce

> fundamental principles such as: the small gastric pouch is a " tool "

> to gain and maintain satiety. Most patients have a fairly clear

> picture that a tool is something that one uses to perform a task

but

> that the tool itself is relatively useless if it is put away on a

> shelf and not used. Patients also seem to appreciate that

developing

> skill in using a tool will make the tool more effective.

>

> NECESSITY FOR LONG TERM FOLLOW-UP:

>

> We emphasize the need for long term follow up care. It is not

> possible in most patients to teach a fundamental change in

lifestyle

> in " theory " by written materials given preoperatively or

immediately

> postoperatively. The fine tuning of the teaching of how to use the

> pouch/tool to prolong satiety is not probably able to be

accomplished

> until the patient redevelops hunger before the next meal, in the

> sixth to twelfth month postoperatively. Techniques on delaying the

> return of hunger are simply not relevant to most patients when they

> are not hungry at all, as they are not in the first six months.

Even

> emphasizing preoperatively the crucial need for long term follow up

> care does not always result in patients returning as they should,

but

> one must set the expectation for those who will be compliant for

long

> term follow up.

>

> PREVENTION OF VOMITING

>

> We believe strongly in the principle that vomiting should be

> prevented if at all possible. This teaching begins in the hospital

on

> the second postoperative day when we initially instruct the

patients

> to drink only out of one ounce cups, and to drink only one-third of

> that ounce at a time with sufficient time between thirds to detect

> fullness. We emphasize that it is not easy to get used to having a

> small pouch volume. For the first few months, the patient's mouth

> will be larger than their stomach, a situation which otherwise does

> not exist in the mammalian kingdom. Also, we keep our standard

> gastric bypass patients with their small edematous outlet on liquid

> feedings for the first six weeks, gradually advancing from totally

> liquid nutrition such as

> Ensure supplemented by protein powder up through a blenderized diet

> and very soft solids. The banded gastroplasty/distal gastric bypass

> procedure with its relatively generous 7.0 cm band on its outlet is

> advanced more quickly to soft solid foods by three weeks.

> Vomiting seldom occurs in the immediate postoperative period unless

> there is an outlet obstruction problem. However, vomiting can occur

> and will do so in most patients at some time after starting on

solid

> food. There are more complexities when eating solid food especially

> rice, pasta, or granola, foods that swell in the stomach after

being

> eaten because they are generally incompletely rehydrated before

being

> consumed. The most frequent cause of vomiting is overloading the

> pouch. We encourage patients to continue to measure their meals

with

> their one ounce cups for weeks, even months, following the surgery

if

> they are experiencing difficulty with vomiting. We emphasize

> repeatedly that they should eat only until " comfortably satisfied "

as

> the word " full " has different meanings to different persons.

>

> SIX WEEKS

>

> Solid food is begun with emphasis on the fine cutting of fibrous

food

> to the size of the fifth fingernail or smaller, thoroughly chewing,

> three or more foods at each meal to prevent wadding up of similar

> fibers, eating only until " comfortably satisfied, " and beginning,

> even at this early date, to teach the concept of no liquids with

> meals for fifteen minutes before meals and for one and a half hours

> after meals.

>

> REASSURANCE OF ADEQUATE NUTRITION

>

> Many patients need reassurance that they can achieve adequate

> nutrition in the postoperative period. Without this reassurance,

some

> patients will deliberately eat six to eight times a day because of

a

> fear of malnutrition (often initiated by well meaning family

members

> and friends). We like to point out that in this short period of

time

> during the pouch growth, there are only two major nutritional

needs:

> protein on the one hand and vitamins and minerals on the other. The

> latter can easily be achieved by the patients routine twice a day

use

> of the vitamin supplements. Therefore, their only responsibility

and

> focus is to eat low-fat, animal-source protein at each meal, three

to

> four times a day. If they do this or simply come close to doing

this,

> they will end their first year post-op with a lower than pre-op

lean

> body mass but one that is appropriate to their body weight at that

> time.

> (reference 4)

>

> MEAL SKIPPING

>

> On the other hand, some patients are likely to skip meals when they

> have no appetite, similar to their behavior previously when their

> appetite has been diminished by over tiredness or illness. We

> emphasize the need for three to four meals a day, including

> breakfast, primarily to meet their needs for protein. We emphasize

> that one-half or more of each meal should be composed of this low-

> fat, animal-source protein (two-thirds of their meal in the distal

> gastric bypass procedures) in the first months until their pouch

> volume is large enough so that they can eat at least two ounces of

> protein at each meal.

>

> ARTIFICIAL SWEETENERS:

>

> We warn our patients to be aware of using artificial sweeteners if

> they are experiencing hunger in this early p.o. period. We have

> evaluated a few patients who experienced very strong hunger

cravings

> in the first weeks or months post-op whose hunger abruptly ceased

> with stopping artificial sweeteners.

>

> AVOIDING ABSOLUTES

>

> There are so many rules that we teach concerning the use of

> the " pouch/tool " that we believe that it is important to emphasize

to

> the patient that it is not necessary to follow every rule all of

the

> time. We actually suggest that it is perfectly all right to break

the

> rules once in a while- the important thing is to be aware that one

is

> breaking the rule and having a reason for it even if that reason is

> simply alleviating frustration. We point out that the only penalty

> for eating a liquidy meal when appetite has returned is the earlier

> return of hunger in the next four to five hour period. There is no

> lasting effect beyond that next meal. We also point out that

deciding

> to take advantage of a social opportunity to eat a high calorie,

> empty calorie meal is the ingestion of a relatively insignificant

600

> to 1,000 calories instead of the 3,000 to 5,000 calories that could

> be consumed in such a meal with a normal stomach volume.

>

> THREE MONTHS

>

> At three months we step up the teaching of the nutritional or

protein-

> containing value of foods related to the " cost " of that protein

food

> in terms of calories consumed, i.e. a gram of cottage cheese

> protein " costs " only five calories, but a gram of cheddar cheese

> protein costs sixteen calories, and peanut butter twenty-four

> calories. Water loading techniques (see below) are introduced at

> three months postoperatively as some patients will begin to see a

> return of appetite before their six month office visit. Overall

fluid

> management is discussed, emphasizing how the Gastric Emptying Test

> illustrates the principles of fluid management (see below).

>

> THREE PRINCIPLES FOR GAINING AND MAINTAINING SATIETY

>

> 1. The pouch needs to be truly filled with adequate wall distention

> with each meal (i.e. no snacking).

>

> 2. Keep the pouch filled over time and slow down the emptying time

> (by eating solid foods and avoiding liquids for fifteen minutes

> before and one and one half to two hours after eating. We

understand

> this to be the most important lifestyle change after the gastric

> bypass procedure. Figure 3 shows the results of a standard gastric

> emptying test using radioactive sulfur with a scrambled egg, bread,

> and milk. With the milk, 90% of the meal volume has exited the

> stomach within forty-five minutes. However, without the milk, only

> 45% of the meal has exited the stomach by ninety minutes.

>

> 3. Finally, adequate protein with each meal. We emphasize three

meals

> a day including breakfast (defined as the first meal of the day

which

> is eaten within one to two hours after arising). We define

> the " enemy " as high calorie liquids. We point out that snacking and

> high calorie liquids cheat the patient because the calories are

taken

> in without offering significant satiety.

>

> FLUID LOADING

>

> Fluid loading is the rapid drinking of a non-calorie or low-calorie

> liquid on an empty stomach in order to achieve a maximal intake of

> water at that time and/or achieve immediate satiety which lasts for

> fifteen to twenty-five minutes. About 80% of the estimated maximum

> capacity at any given time should be drunk rapidly over fifteen to

> thirty seconds and then topped off with swallows until full satiety

> is reached. Patients rather rapidly determine what their capacity

is,

> and it usually is between eight to twelve ounces when the Cottage

> Cheese Test volume is four to six ounces. The fluids should not be

so

> cold as to be uncomfortable, but it is not necessary to be warm.

The

> mechanism of action is presumed to be the distention of the Roux

limb

> with subsequent contraction, stopping the progression of fluid

> downwards and backing up the volume and pressure into the small

pouch

> and, perhaps, even into the distal esophagus. Fluid loading works

> with the banded gastroplasty as well but not quite as effectively.

> The mechanism here is probably primary distention of the pouch with

a

> fluid as it is passing through. The volume required is usually

> somewhat greater, but it still is far less than two to four glasses

> of water required in a normal sized stomach. Clearly, this small

> proximal pouch is quite sensitive to distention, and the satiety

> gained from that distention lasts far longer than the distention

> itself. We teach patients to fluid load before each meal in order

to

> help prevent post meal thirst, but also to fluid load whenever they

> feel the sensation of hunger and are tempted to snack.

>

> POST PRANDIAL THIRST:

>

> It is important that the patient be fully hydrated before coming to

> the next meal because the solute load of the meal will create

> postprandial thirst. It seems intuitive that persons cannot

tolerate

> thirst any more than they can tolerate hunger over the long run as

> both hunger and thirst are primary noxious stimuli. Initially, when

> the functional pouch volume is quite small, the solute load is

> correspondingly small, and the patient may not see the point of

> adequate rehydration and pre-meal fluid loading. However, as the

> pouch volume increases and the solute load increases, it becomes a

> significant issue in maintaining that important proscription of

> avoiding liquids during and for an hour and a half after the meal.

>

> URGENCY

>

> In these first months we like to emphasize to patients that their

> golden opportunity for maximizing their weight loss is in the first

> six months after surgery. We illustrate this with the weight loss

> curve, with its rapid downward sweep, with two-thirds of their

weight

> being lost in the first six months postoperatively. The Cottage

> Cheese Test shows that two-thirds of the pouch growth occurs in the

> first six months. Therefore, we teach our patients that every day

> during this early period the exercise and activity that they do

will

> be more effective in burning calories in excess of their calorie

> intake than the same amount of activity/exercise the following

> day. . . and a little less effective than the previous day based on

> progressive pouch growth. I.e. every single day the patient should

> take advantage of their present opportunity and get as much

activity

> as they can, knowing that never again will that same amount of

> activity result in as much weight loss. We try to give them a sense

> of urgency about getting the most out of every day.

>

> SIX MONTHS

>

> At this point, or soon after, our patients are beginning to get

> hungry before their next meal, and we accelerate the teaching of

> satiety mechanisms and the prevention of post meal thirst. As the

> meal solute volume increases, they need to push enough fluids in

the

> two to three hours before the meal to gain good hydration with

final

> water loading fifteen minutes before the next meal.

>

> INTAKE INFORMATION SHEET AS A TEACHING TOOL

>

> At each visit from three months to two years, the patient is asked

to

> complete a form before they come into the office. The form queries

> them about their performance on the principles of pouch use (as

well

> as vitamin usage, exercise, pathological symptoms, etc.). This form

> is designed so that it is also a teaching tool- each question

reminds

> the patient about the principles of the use of their pouch/tool.

> Many, if not most, patients do very well, and their weight loss is

> progressive and satisfying. Some struggle to make the lifestyle

> changes necessary, but with these periods of intermittent

monitoring,

> encouragement, and teaching they progressively learn and most do

> well. A few patients never seem to understand or to remember these

> simple principles even though they might be quite intelligent,

> capable persons in other facets of their lives. . .

>

> HONEYMOON SYNDROME

>

> The profound satiety that patients experience in the first six

> months, along with the rapid weight loss due to intake restriction,

> can lead certain patients to believing that these circumstances

will

> never change in spite of the clear teaching of our patient

> information booklet and clinic visit handouts. For these patients,

we

> will then see a slackening off on their food selection and liquid

> calorie control and see them indulge in more recreational eating.

> They will cut back on their exercise as they seem to be losing a

> great deal of weight without exercising. Their weight loss will

> subsequently slow. We have dubbed this situation the " honeymoon

> syndrome " and tried to educate our patients, even in our

preoperative

> informational booklet, that they can expect this temptation to

occur

> and that they must not get " suckered " into a false sense of comfort

> that leads them to not make a sufficient effort in their own behalf

> and miss this golden opportunity for weight loss. We have found

that

> an effective tool for identifying and reality-orienting the patient

> is to graphically compare that patient's weight with the mean

weight

> loss of the group as a whole. Whatever the patients beginning

weight

> is, we would expect them to parallel the weight loss curve. If

their

> weight deviates from the expected, we should be able to find a

reason

> for it and to correct it if the patient is willing to learn and

make

> this needed lifestyle change.

>

> EXERCISE

>

> Although this chapter is about understanding the function of the

> small proximal gastric pouch and how it relates to patient

> management, a word must be mentioned about exercise. We believe

that

> the scientific data overwhelmingly demonstrates that 1) exercise is

a

> critical part of a healthy lifestyle for patient and doctor alike,

> and 2) that exercise is necessary to maintain weight loss in the

> obese patient. Therefore we believe it must be a critical part of

our

> postoperative patient teaching and encouragement. Exact details are

> beyond the scope of this presentation, but we do emphasize to the

> patients that the feelings of vigor and energy are in no way

> guaranteed by a slender figure. Observations of people on any city

> street confirm this. . . We emphasize that the release of

endorphins

> with aerobic exercise improves emotional stability and mental

clarity

> and helps any person to cope with the deprivations and annoyances

of

> everyday life. Endorphins, adrenalin, norepinephrine, etc., also

act

> in an antidepressive manner. But most importantly, especially in

the

> first six month period when the gastric pouch is so small, regular

> aerobic exercise maintains, or even improves basal metabolic rate

> that is observed to drop during rapid weight loss.

>

> THE IDEAL MEAL FOR WEIGHT LOSS

>

> The ideal meal for weight loss is one-half of the meal volume up to

a

> total volume of two to three ounces of animal-source, low-fat

protein

> plus filling the rest of the pouch volume with low starch

vegetables

> and solid type fruits such as apples and pears. Cut finely and

chewed

> well, these foods represent coarse, solid food choices that are

> likely to stay in the pouch longer and offer good nutritional

value.

>

> VOLUME VERSUS CALORIES

>

> A person with a normal stomach tends to judge how much he/she needs

> to eat at a given meal by approximately how many calories are in

that

> meal (although not necessarily thinking of calories as such). In

> other words, we know that we are going to be unpleasantly hungry

> before dinner if our noon meal consists of a green salad and a

couple

> of ounces of cottage cheese. Calories are what keep us from getting

> hungry between meals. On the other hand, the post-op gastric bypass

> patient needs to learn to think about the volume and consistency of

> food choices rather than their caloric content when judging how to

> prevent getting hungry before the next meal. I recall a lecture I

> once attended in which the lecturer pointed out that one or two

> sticks of butter could meet our entire calorie needs for the day

and

> could be easily consumed by even the small post-op gastric bypass

> pouch. However, that same number of calories in the form of non-

> starchy raw vegetables could not be consumed by a person with a

> normal stomach in only three meals a day. There is an enormous

> variation between calories and volume, and a patient needs to learn

> how to " think volume " when making food choices to gain and maintain

> satiety in a mature small gastric pouch.

>

> ISSUES FOR LONG TERM WEIGHT MAINTENANCE

>

> The previous comments are primarily designed to deal with patient

> issues in the first year following a gastric bypass procedure.

These

> issues should seamlessly slide into long term weight maintenance

and,

> indeed they do so in most persons.

>

> COUNTER-INTUITIVENESS OF FLUID MANAGEMENT:

>

> It is clear that avoiding liquids with meals and pushing fluids

> between meals is counter intuitive. The large capacitance of a

normal

> stomach is a great convenience factor for that person and, truly,

all

> animal life. There is a resistance to learning this technique, and

> clearly it is counter intuitive to the experience of the

individual.

> However, if it is important that solid food be taken rather than

> liquidy food to maintain satiety, then it is clearly important to

> avoid liquids with meals or soon after meals as the liquid will

> simply make the food more soup-like and soft and allow more rapid

> emptying of the pouch and, therefore, shorten the period of

satiety.

>

> SUPPORT GROUPS

>

> We have found that support groups are very effective in reinforcing

> the principles of the pouch/tool use. Many, if not most, patients

> will explore these principles on their own by using them and then

for

> a time not using them. Some patients on their own become convinced

of

> the value of these principles through this natural experimentation.

> However, others may lose their way. The support group offers an

> excellent feedback mechanism for individuals who need reinforcement

> of the principles of the pouch use. Sometimes, the feedback of

their

> peers is more effective than that of the parental figures in the

> surgeon's office.

>

> TEETER-TOTTER EFFECT

>

> One " visual " that we use when discussing weight maintenance is that

> of a teeter-totter. On one end of the teeter-totter is the

> exercise/physical activities, and on the other end is the meal

choice

> discipline and fluid restrictions. When one has a large amount of

> exercise and activities, the teeter-totter swings down on that end,

> and the amount of effort that need be placed on diet discipline

> lightens up. When one is light on the activity/exercise, one has to

> be much heavier on the diet discipline side. If one is light on

both

> exercise and diet discipline, the whole teeter-totter moves upward

as

> weight is gained. On the other hand, if one is " heavy " on both

> exercise and diet discipline, the teeter-totter bar goes down, and

> weight is lost.

>

> TOO MUCH WEIGHT LOSS

>

> There are a group of patients in our practice, approaching 15%, who

> lose too much weight in the one to two year period postoperatively.

> Inevitably, these individuals were only 100 to 150 pounds

overweight

> to start with and are good exercisers. We encouraged them to taper

> off their efforts with diet discipline (maintaining their exercise

> routine and thus their vigor) by adding some fat back to their

meals

> and eating a fourth or fifth meal a day with less discipline on the

> fluid management. Basically, it is an exercise on " how to beat the

> pouch. " The pouch can be beaten by one, liquid high calorie meals;

> two, frequent meals or grazing; three, eating a meal over thirty to

> forty-five minutes; four, adding liquid to meals to enhance gastric

> emptying; five, liquids are taken shortly after eating which

> increases gastric emptying and decreases the satiety period. Some

> patients take our advice and taper off their weight loss before

they

> go underweight. However, a small but significant group of patients

> actually go underweight because all of our patients have

experienced

> the rapid and frightening return of severe hunger cravings when

going

> from one of their many diets to trying to eat normally once again.

> Very similar to a bear coming out of hibernation, their suppressed

> appetite center seems to burst out with vigor in order to save the

> life of this person who the appetite center sees as a normal weight

> person having suffered in a famine. Many patients at this point

have

> not yet fully accepted that they have had a true anatomic and

> physiologic change from their operation and that, using the

> principles of the pouch/tool, a return of this overwhelming

appetite

> will not occur. For these persons, it is not until their lean body

> mass is effected and they lose their delightful sense of vigor that

> they will begin to " break the rules " and gain some needed weight

> back. This is probably the primary reason why, in most bariatric

> surgical practices, the weight loss curve bottoms out at eighteen

to

> twenty-four months with a rise at two to three years. This rise has

> been erroneously interpreted as most patients regaining 10% to 15%

of

> weight from the nadir of their weight loss.

>

> BARIATRIC MEDICINE

>

> A much more common problem is that of patients who have not lost as

> much weight as they would like and are plateauing at a level above

> their goal weight. Bariatric medicine techniques can be useful in

> helping our postoperative patients who find themselves stuck on a

> plateau one or more years postoperatively. However, there can be a

> problem with standard weight control and dietary teaching of

> Bariatric medicine. The frequently used recommendations of frequent

> small feedings or liquid calorie fasts such as a protein sparing

> modified fast, neutralizes the satiety function of the pouch/tool,

> and tends to negate the teachings of the principles of the pouch

use,

> and therefore is probably not an optimum way of managing the

patient.

>

> SUMMARY

>

> The principles of the postoperative bariatric surgical follow up

> management are as follows:

> 1. Understanding the fundamentals of the anatomy and physiology of

> the pouch/tool.

> 2. Evaluating the patient's appropriate or inappropriate use of the

> tool- What is lacking? What is being done well?

> 3. Instruct patient with words, drawings, analogies, encouragement,

> and passion, on not only what to do but why it needs to be done.

>

> The goal is to make the patient become fully knowledgeable about

how

> to control their own weight over the long term through the

> appropriate use of their pouch/tool, combined with a reasonable

> amount of exercise.

>

> EVALUATION FOR WEIGHT LOSS FAILURE

>

> Evaluating a patient who is progressively regaining weight can be

> relatively simple- or extremely difficult. The first principle is

to

> determine that the gastric pouch is anatomically intact. If it is

not

> intact, it should be made intact by a revision procedure. Only when

> the surgeon can be reassured that the pouch is intact does the

> complex part begin- evaluating how and why the patient is not using

> the pouch/tool properly, and/or getting a reasonable amount of

> exercise.

>

> We need to know three things about the small gastric pouch. First,

is

> the staple line intact; second, is the outlet intact; and third, is

> the pouch reasonably small in size.

>

> The upper GI series with thick barium is the basic tool for

> evaluating intactness of the staple line and the outlet. If the

pouch

> has been stapled in continuity with the rest of the stomach, we

must

> confirm that the staple line remains intact. An eventration of the

> staple line will create two gastric outlets leading to rapid pouch

> emptying, early loss of satiety, and thus early return of hunger.

An

> important clue from the patient's history is the presence of a

> marginal ulcer after a gastric bypass. Marginal ulcers do occur,

> occasionally, with an intact staple line. However, they are more

> common with a small hole in the staple line that results in food

> stimulation of the antrum. If there is a staple line eventration,

the

> marginal ulcer is unlikely to be able to be controlled without

> reoperation and closure of that eventration, preferably with

complete

> division of the small pouch from the distal stomach.

>

> The upper GI series with thick barium in the hands of an

experienced

> radiographer can usually give the bariatric surgeon a reliable view

> of the diameter of the gastric outlet. A diameter of over 18-20

> millimeters is usually associated with weight regain, and we term

> this " outlet failure. " Outlet failure, like a staple line

> eventration, causes rapid emptying of the pouch, early loss of

> satiety, and early return of hunger.

>

> On the other hand, weight regain can occur as a result of an outlet

> diameter under 7-8 millimeters which can lead to persistent

vomiting

> of solid foods and gradual persuasion of the patient towards the

Soft

> Calorie Syndrome with resultant rapid pouch emptying, early loss of

> satiety, early return of hunger, and weight regain.

>

> The upper GI series is less effective for evaluating pouch volume

> because of the fact that barium is very much of a liquid. To assess

> pouch volume, you must turn to the patient's history of the size of

> the meal that he/she can consume within a short five to fifteen

> minute time frame, and/or to the Cottage Cheese Test (see above).

>

> In the patient whose gastric pouch seems to be anatomically intact

> and yet he/she is still regaining weight, the evaluation becomes

more

> complex. The usual finding is that the patient is not following the

> principles of the use of their pouch/tool and/or is extremely

> inactive physically. There are four problems that occur with some

> frequency: the patient has never been taught/or does not understand

> how to use the tool; the patient is significantly depressed; or

loss

> of contact with a bariatric practice and other bariatric patients

and

> a gradual erosion of following the principles; or the patient is

> truly noncompliant and will not take responsibility for his/her own

> behavior.

>

> LACK OF TEACHING

>

> An excellent example of the lack of teaching/understanding of how

the

> pouch works is found in the history of GC. GC is a 62-year-old

woman

> who presented in consultation for a total regain of her weight and

> complaint of constant hunger, sixteen years following a gastric

> bypass procedure in Cambridge, Massachusetts. She stated that she

had

> not seen the surgeon beyond the six week follow up visit. She

> understood nothing about how to use her gastric pouch. She

initially

> lost fifty pounds and then another forty pounds further with the

help

> of a commercial weight management program. For the next ten years

she

> yo-yoed up and down with the usual peer group and doctor supported

> programs with a gradual increase in weight and the usual hunger and

> deprivation syndromes relating to these programs. She then

developed

> myasthenia gravis and her weight regain escalated to her

preoperative

> weight, resulting in the referral. At the time of the referral she

> was being treated effectively for myasthenia gravis and was

> reasonably active, being able to walk over a mile at a time. Her

> weight loss curve with its abrupt turn around and rapid weight loss

> (figure 4) could be consistent with a revision reoperation.

However,

> there was no revision done. After evaluation of her pouch/tool with

> an upper GI series and a Cottage Cheese Test/functional meal volume

> estimation, she was given the basic instructions of how to use her

> pouch/tool, the same given to all of our postoperative patients.

Her

> ensuing and continuing weight loss is impressive, but more

impressive

> to the patient is that she is not experiencing any distressing

hunger

> cravings, food fantasies, or food dreams as she had experienced

with

> all of her previous efforts, since the first months after her

gastric

> bypass procedure sixteen years ago.

>

> DEPRESSION

>

> Depression is a powerful inhibiter of success after bariatric

> surgical procedures. A small but significant number of our patients

> have been doing well following their gastric bypass procedure only

to

> drop out of sight for a time and then reappear with a significant

> weight regain. Upon evaluating these patients, it would appear that

> in many instances they seemingly deliberately reverse all of their

> learned principles of the use of their pouch/tool: grazing and

> snacking through much of the day, drinking high calorie liquids,

> drinking liquids with meals, and stopping their exercise, even when

> they are intellectually aware that exercise in itself releases

> numerous vasoactive substances which act like antidepressants. DB

is

> a 46-year-old woman who had an excellent initial weight loss

> following a gastric bypass procedure (figure 5). While still in the

> first year after her gastric bypass, her life, already made

difficult

> by divorce and economic circumstances, became severely disrupted

when

> her only daughter developed a drug problem, an abusive

relationship,

> and finally HIV, and was forced to give up her newborn child. Her

> weight regain was dramatic. However, even more dramatic was her

> weight loss once her depression eased, and she was able to look

after

> herself once again. She relates that she did nothing dramatic such

as

> fasting. She simply returned to using her pouch/tool in the manner

in

> which she had been taught and resumed a moderate exercise program.

> What can the bariatric surgeon do when patients are obviously

> depressed and regaining weight? Obviously, the most important thing

> is to steer them to professional counseling, if they are not

already

> in counseling. Then, the surgeon can be encouraging. We can

encourage

> them to continue to use the tool as best as they can; we can

> encourage them to return to exercise which will improve the spirits

> and reassure them that the improvement is " deserved, " " because you

> really are a good person, and you deserve to feel better. . . " Most

> of all, the surgeon can reassure them that the pouch/tool is not

> ruined by this overeating and gradual weight regain if it does not

> result in persistent vomiting of solids. When they are ready once

> again to use their pouch/tool, it will be there for them, and they

> will be able to once again lose weight without being hungry.

>

> EROSION OF THE USE OF THE PRINCIPLES:

>

> In a third subset of weight maintenance failure patients, a subtle

> weight creep can occur to patients who are otherwise compliant, non-

> depressed, and have intact pouches. The patient will see it

> as " struggling " with his/her weight, and by definition, he/she will

> not have seen you in follow up and will have usually lost contact

> with the support group or other bariatric surgical patients. There

> seems to be a progressive erosion of following the principles of

the

> pouch/tool use. This may be due to denial as seen in diabetic

> patients, or it may be due to the influence of their peer group and

> the fact that some of the principles of the use of the pouch/tool,

> especially fluid management, are counter- intuitive and counter to

> behavior of their peer group. The patient will often not come back

> for evaluation because " I know what I'm doing wrong! " (meaning that

> he/she is eating the wrong things and too often), and these

patients

> will internalize their " failure " with an increasing sense of guilt

> which itself acts as an inhibition to coming back to their

surgeon's

> office for help.

> From the beginning, in our preoperative teaching, we emphasize the

> possible need for a " refresher course " in the use of the principles

> of the pouch/tool at some time in the future. Some patients still

do

> not return. The trick is identifying these patients and somehow

> getting them back either into the office or into a support group.

> In these three examples- lack of teaching, depression, and gradual

> erosion of the use of their tool, weight once regained can be lost

> once again if the pouch is anatomically intact and the patient

> decides to use it, or learns how to use it or relearns how to use

it.

> In these three examples, we are working with compliant, reasonably

> responsible persons who, when they can, are willing to take

> responsibility for their own behavior.

>

> TRUE NON COMPLIANCE:

>

> The most difficult problem is determining, and being comfortable

with

> that determination, when a patient is being fundamentally

> noncompliant and obstructive. This type of individual may leave

your

> care and go to others complaining about a " personality conflict, "

or

> perhaps even that you have not given them the time and attention

that

> they need and deserve. Inexplicably, some will actually stay in

your

> care. In this instance, when the patient tends to return perhaps

even

> more frequently than usual, depression will be more likely the

> underlying mechanism rather than noncompliance. It can be difficult

> to be reasonably sure of what is going on in one or two visits. The

> truly noncompliant patient will very likely end up with multiple

> revisions and/or a reversal due to weight regain or complications.

> This kind of patient is often quite resistant to counseling, but I

> know of no other management option that offers much hope for

success.

> Luckily, this type of patient represents a very small minority of

our

> patients. Obviously, prevention in the form of patient selection is

> better than cure, but after twenty-three years of a bariatric

> surgical practice, I have yet to be able to effectively identify

> these persons preoperatively. I have, in fact, suspected

significant

> noncompliance in a number of my patients who have turned out to be

> quite compliant particularly after control of other problems, such

as

> sleep apnea, that effect understanding and complying with our

> instructions. With the current lack of an effective psychological

> screening tool to reliably identify these individuals, I tend to

lean

> towards giving each person a chance at a good and healthy life

> provided by bariatric surgery.

>

> BIBLIOGRAPHY

> 1) Mason, EE, Personal Communication, 1980

> 2) Barber, W, Diet al, Brain Stem Response To Phasic Gastric

> Distention. Am J. Physiol 1983; 245(2): G242-8

> 3) Flanagan, L. Measurement of Functional Pouch Volume Following

the

> Gastric Bypass Procedure. Ob Surg 1996; 6:38-43

> 4) Rosemurgy, A.

>

>

>

>

>

>

>

>

>

[Guest guest]

---

What a great article... I have been putting some of those principles

to use and have broken my plateau and lost 4lbs YAY I am eating

much more protien, and really working on fluid loading and the

hardest thing is working on drinking BEFORE MEALS... I was drinking

with meals, not much, but some, and now I won't be doing that any

more.. I found especially interesting the part where the woman had

regained her weight over the 16 years and by using these principles

was able to lose weight again, since according to thise article I am

done with the honeymoon stage, which I had already figured out..and

the larger amounts of protien makes me feel full longer and works

well.This article should be part of the clos.net site for all post-

ops it really stresses proper managment of the " tool " .

Suzanne

1.10.01

-64

In @y..., " wwmohler " <wwmohler@s...> wrote:

> Here is an article that might shed some light on the drinking etc.

with meals along with some other information. Now although it was

not written by our beloved Dr. R, (Dr. R feel free to chime in, maybe

he even knows the Dr. that wrote this,) there is some information I

have found useful.

>

> POST-OP TEACHING AND EVALUATION

>

> By Latham Flanagan, Jr., M.D., FACS

>

> Article is sectioned by capitalized categories.

>

> INTRODUCTION

>

> >From our earliest experiences in bariatric surgery, we have been

> intrigued with the question " How does our operation cause weight

loss

> and maintenance? " As we talked to the public, and even our medical

> peers, it became evident that a common concept of the uninformed is

> that the small gastric pouch simply mechanically restricts intake,

> preventing the post-op patient from eating too much. Indeed,

> superficially, it may appear that way especially in the first 3-9

> months post-op. However, even a short experience with following our

> patients shows us that with a meal size of even three to five

ounces,

> certain patients will stop losing weight and start to regain. We

also

> note that two to five or more years postoperatively certain

patients

> seem to have a large meal volume of six to ten ounces but still

> maintain good weight control without an noxious degree of hunger.

It

> has become clear with experience that the principle of weight

control

> is the achievement of satiety, or the absence of abnormal hunger,

> associated with the ingestion of the appropriate number of calories

> sufficient to meet the person's need. If adequate satiety is

> achieved, our patients are successful. . . And they fail if that

> satiety is not achieved. When patients " fail " there is a tendency,

> even among bariatric surgeons, to pass it off as " noncompliance. "

> Certainly, this can be an appropriate evaluation in a few persons

who

> are not willing to accept responsibility for the lifestyle changes

> necessary to make the small gastric pouch function properly. But,

is

> this the problem for the majority? I think not. When failure does

> occur, it is usually the inability to maintain the post meal

satiety

> long enough to prevent snacking before the next meal time arrives.

> Also, it could be due to ingestion of a large number of calories in

a

> form that is somewhat hidden to the patient and is not responsive

to

> the gastric pouch restriction, especially high calorie liquids.

>

> HYPOTHESES OF POUCH FUNCTION:

>

> At this point in time what have we learned about how the small

> gastric pouch works? In the form of an hypothesis, we can now state

> that the basic mechanism is that of stretch of the pouch walls with

> eating of a small meal, or even the drinking of fluid. This stretch

> is sensed by the stretch receptors in the pouch wall and relayed by

> neural pathways to the appetite centers in the hypothalamus by way

of

> the tractus and nucleus solitarius. The second hypothesis is that

> successful maintenance of satiety depends upon the creation and

> maintenance of a small gastric pouch and a small gastric pouch

outlet

> (Mason- reference 1). The third hypothesis is that the observed

> increase in functional meal volume over the months and years

> following a gastric bypass procedure is due to the process of

> hyperplasia and is not wholly or in great part due to noncompliance

> on the part of the patient. The fourth hypothesis is that

> understanding of these principles and effective teaching to a

> compliant patient results in better weight loss and maintenance

than

> if the teaching is not accomplished.

>

> PUBLISHED DATA

>

> To support these four hypotheses, we have two pieces of reasonably

> good scientific information from peer reviewed published articles.

> From that point we must rely on observational-based science.

>

> Our first question is how does the small gastric pouch create

> satiety? Considerable insight on the neurological pathways of

satiety

> has been obtained through the work of Barber, a Ph.D.

> veterinarian, and his associates who published a paper in 1983

> entitled " Brain Stem Response to Phasic Gastric Distention. "

> (reference 2) They placed a balloon in the stomachs of anesthetized

> cats and surrounded the stomach with a strain gauge.

Microelectrodes

> were placed in the nucleus and tractus solitarius of the brain

stem.

> They found a population of neurons that faithfully monitor moment

to

> moment changes in gastric wall tension. The discharge frequency to

> wall tension did not adapt for the twelve hour period of the

> experiment. This response was dependent upon an intact vagal nerve

in

> these cats. They concluded that " these neurons may serve as a

> critical link between the stomach and higher centers in the

conscious

> perceptions of fullness. " It seems particularly impressive and

> interesting that the neurons continued to fire at an accelerated

rate

> for as long as twelve hours, if the gastric wall tension remained

> high.

>

> Another question of considerable importance to the thinking of a

> bariatric surgeon is what is the fate of the small gastric pouch?

> Does it enlarge at all after the surgical procedure? If it does

> enlarge, is it because the operation was done improperly? Was it

> because of gross patient noncompliance and gorging? Or, is it due

to

> the kind of hyperplasia seen throughout the gastrointestinal tract,

a

> response to loss of function? Dr. E. E. Mason, at one of the Iowa

> Bariatric Symposia in the early 1980's, suggested that it might be

> useful to ask patients to eat cottage cheese in a structured manner

> in order to attempt to determine their functional meal volume at

> different times postoperatively. I took the idea home and began

> asking all of my patients to do this simple test with each one of

> their follow-up postoperative visits at three, six, nine, twelve,

> eighteen, and twenty-four months. We continued to do this over the

> next decade (and subsequently to date), and figure 1 reveals a

> regular, progressive, stepwise increase in functional pouch volume

> over time that strongly suggests the orderly process of

hyperplasia.

> Stabilization occurred at two years at a mean pouch size of six

> ounces with a wide range of three to nine-ten ounces. The pouch

> appears to not get larger after the second year. (reference 3)

These

> gastric bypass pouches were created as a vertically oriented, 30 cc

> pouch measured against both volume and pressure of 70 to 85 cm of

> water. The curve of pouch enlargement is the inverse of the weight

> loss curve.

>

> We then proceeded to compare the patients' weight losses at one and

> three years to pouch sizes at one year. Figure two reveals that

there

> was no difference in percent excess weight loss at one year, with

the

> different pouch sizes within this range of up to nine-ten ounces.

We

> then compared the largest third of pouch sizes to the smallest

third

> of pouch sizes, and still there was no significant difference in

> weight loss at one year or of maintenance at three years. This

> finding is, perhaps, the most important result to come from the

> Cottage Cheese Test work. It strongly suggests that within these

> limits of pouch sizes that success in weight loss and maintenance

> depends not only on having a small gastric pouch but even more so

in

> how the patient uses their " pouch/tool. " If this is true, then the

> implication is clear that learning how to use the pouch/tool

> effectively is important and that it is our responsibility as

> bariatric surgeons to see that effective teaching is made available

> to our patients over this two year period of changing intake and

> satiety control. In brief, the Cottage Cheese Test data tells us

that

> within the context of a small meal volume, lifestyle change

including

> exercise is the most important variable. The stepwise progressive

> growth in the functional pouch volume (meal size) probably defines

> the rate of weight loss for the patients taken as a whole, but the

> degree of weight loss and maintenance for the individual patient is

> more dependent upon that patient's ability to make the required

> lifestyle changes: proper use of the pouch/tool and adequate

amounts

> of activity and exercise.

>

> OBSERVATIONAL-BASED MEDICINE

>

> Observational-based medicine has a long history of respect going

back

> to the early work of two of my personal surgical heros, s

> Vesalius and Ambrose Paré. Indeed, we often refer to the " art and

> craft of surgery " . Although we do make great effort to have a

> scientific basis to our surgical decision making, ideally with

> prospective randomized studies or double blinded studies, at this

> point in time the majority of what we do is based on empiricism, or

> observational-based medicine. The observations that I would now

like

> to share from my own personal thirty-three years of experience in

> bariatric surgery are also shared by many other experienced

bariatric

> surgeons of my acquaintance, although not all would agree with all

of

> these principles.

>

> For the first fifteen years, although I remained busy in a general

> surgical practice, my primary interest, bariatric surgery, lagged

> because of the lack of patient material, primarily because of the

> profound discrimination of medical insurers against the morbidly

> obese in our area of the country. What appeared to be a

disadvantage

> initially became an advantage, as I thereby had the opportunity to

> follow almost all of my patients personally during that time. As

> there was little known about the mechanism of action of the gastric

> bypass procedure, I spent a good deal of my time thinking about

> possible mechanisms and observing the differences between patients

> with good weight loss and those with poor weight loss. Since the

> beginning, I have performed the short limb gastric bypass procedure

> (GBP), only adding the malabsorption procedure of the banded

> gastroplasty/distal gastric bypass procedure (BG/DGB) in 1992. The

> BG/DGB also uses a small, vertically oriented gastric pouch quite

> similar to the gastric bypass procedure pouch, the difference being

> that the outlet is controlled by a band as in the vertical banded

> gastroplasty and silicone ring gastroplasty, etc., instead of a

> gastroenteric anastomosis. My observations seemed to be similar for

> the two procedures, although not identical for both. The Cottage

> Cheese Test was done only with the GBP. Considering the above, what

> do I think that I have learned?

>

> The following are observations that may have an effect on the

> function of the gastric bypass pouch:

>

> 1. We have come to understand that the accomplishment of satiety,

or

> suppression of hunger, is fundamental to the success or failure of

> bariatric operations.

> 2. We have come to understand that success relates anatomically to

> creating a small pouch that remains relatively small and a small

> outlet that remains relatively small (Mason).

> 3. Meal volumes much larger than ten-twelve ounces usually result

in

> failure of weight maintenance.

> 4. The use of the thick, less distensible lesser curve of the

stomach

> is believed to be important by many surgeons.

> 5. Satiety is achieved by increasing the tension on the gastric

pouch

> wall, thus stimulating the stretch receptors.

> 6. Maintaining satiety is dependent upon maintaining some portion

of

> that stretch for an undefined period of time.

> 7. For either the gastric bypass or the banded gastroplasty, almost

> all patients have a profound satiety, 24 hours a day, in the first

> six months or so following their bariatric surgical procedure. They

> do not redevelop a normal appetite preceding the next meal until

six

> to twelve months postoperatively.

> 8. If for any reason the patient is NPO for a significant period of

> time like eight to twelve hours, a profound hunger will be

> experienced.

> 9. In the mature pouch at one plus years post-op, the more solid of

> food that a patient eats, the longer is the satiety period after

the

> meal.

> 10. Almost all patients after the gastric bypass procedure, and

most

> patients after the vertical banded gastroplasty, achieve fifteen to

> twenty-five minutes of satiety after simply rapidly drinking water

to

> a point of fullness, or " water loading. "

> 11. Some patients fail the banded gastroplasties in association

with

> shifting their diets to mostly liquids or soft solids, the " soft

> calorie syndrome, " and they fail by becoming hungry too soon before

> their next meal and giving in to snacking between meals because of

> that hunger.

> 12. Responsible patients who carefully follow the principles of

using

> their " pouch/tool " continue to have a reliable and progressive

weight

> loss and weight maintenance.

> 13. Patients who approach or become underweight at one to two years

> following bariatric surgery can reverse their weight loss with

> reversing the principles of using their pouch/tool.

>

> HOW DO WE INTERPRET THESE OBSERVATIONS?

>

> POUCH SIZE:

>

> It seems intuitive that the functional meal volume must stay small

in

> order to limit the patient's caloric intake and provide satiety.

What

> is not clear is how small it must remain. The Cottage Cheese Test,

> discussed previously, gives us some insight. With the data from

that

> test, the pouch size/functional pouch volume can exceed six to

seven

> ounces and still give as good a satiety as a smaller pouch.

> Obviously, this depends on patient behavior such as choices of

> specific foods eaten, frequency of meals, fluid management, and

last

> but certainly not least, the amount of activity/exercise.

>

> OUTLET SIZE:

>

> The outlet of the small gastric pouch is a fixed ring, either fixed

> by scar or fixed by a band or both. There is no longer a valve that

> controls the rate of emptying. Therefore, it is intuitive that

> liquidy foods will exit the pouch faster than more solid foods.

> Certainly, no pouch can control the amount of fluid consumed, nor

> would it be tolerable if that could be done. Therefore, the

calories

> contained in high calorie liquids have the ability to defeat weight

> loss or maintenance.

>

> EARLY PROFOUND SATIETY:

>

> The mechanism of action of the profound satiety of the first six

> months is presumed to be due to the necessity of the patient

drinking

> water very frequently throughout the day in order to meet minimal

> fluid requirements. From our experience with " water loading, " we

note

> that water loading will give almost all patients fifteen to twenty-

> five minutes of satiety if done when they are hungry. Presumably,

the

> frequency of water drinking during the first six months simply

> overlaps these short periods of water-induced satiety.

> The return of appetite in our patients at about six months

correlates

> with two-thirds of the pouch hyperplasia as determined by the

Cottage

> Cheese Test. The average pouch size then is approximately four

ounces

> when the lesser curve pouch is created at one ounce in volume at 70-

> 85 cm of water pressure. The mechanism of action is presumed to be

a

> less frequent stimulation of stretch receptors in the gastric pouch

> wall because at this point the patient can ordinarily drink six to

> eight ounces of water at a time.

>

> OPTIMUM MATURE POUCH:

>

> How might we describe the optimum mature pouch? The pouch seems to

> work best when one, the outlet is not too restrictive to allow

eating

> of solid foods such as meat and vegetables but two, the outlet is

not

> so large as to allow early emptying and premature loss of satiety

> from solid food, and three, the pouch is not too large to allow

over

> eight-nine ounces a meal.

>

> IDEAL MEAL PROCESS:

>

> What might be the ideal meal process? The ideal meal process

includes

> timing of meals. To get through the day without hunger on three

meals

> a day, there needs to be about five hours between breakfast and

> lunch, lunch and dinner, and dinner and bedtime. It becomes evident

> that if there are only three hours between breakfast and lunch, and

> then six to seven hours between lunch and dinner, that one cannot

> expect satiety to be maintained over the full seven hours, no

matter

> how solid the food eaten, short of frank outlet obstruction. For

the

> optimum meal, a more solid type of food such as finely cut meat and

> minimally cooked or raw vegetables should be eaten. The meal should

> be taken over five to fifteen minutes, depending upon the

functional

> pouch volume. Stringing a meal out over thirty to forty-five

minutes

> or more is one of the techniques that has been used to " beat the

> pouch. " Following the meal, take no liquids for one and a half

hours,

> or even two hours if satiety is lost too soon before the next meal.

> Then, after that one and a half to two hours is up, begin drinking

> low or no calorie fluids somewhat slowly (in order to avoid over

load

> symptoms if there is still considerable food in the pouch) and then

> progressively accelerate drinking up to fifteen minutes before the

> next meal. The patient should be urged to drink a lot of water in

the

> two hours or so before the following meal. This period of

rehydration

> ends with a " fluid load " fifteen minutes before the next meal.

> However, a single pre-meal fluid load can never adequately

rehydrate

> an individual who has not already been drinking a lot of fluid.

Fluid

> loading can be done any time in the two to three hours preceding

the

> meal if hunger is experienced. This use of the fluid load can

> substitute for taking in unwanted calories through snacking.

>

>

>

> THE MANAGEMENT OF PATIENT TEACHING AND TRAINING

>

> Postoperative patient instruction begins with setting appropriate

> expectations preoperatively through the information provided in

your

> thorough patient information booklet. This is the time to introduce

> fundamental principles such as: the small gastric pouch is a " tool "

> to gain and maintain satiety. Most patients have a fairly clear

> picture that a tool is something that one uses to perform a task

but

> that the tool itself is relatively useless if it is put away on a

> shelf and not used. Patients also seem to appreciate that

developing

> skill in using a tool will make the tool more effective.

>

> NECESSITY FOR LONG TERM FOLLOW-UP:

>

> We emphasize the need for long term follow up care. It is not

> possible in most patients to teach a fundamental change in

lifestyle

> in " theory " by written materials given preoperatively or

immediately

> postoperatively. The fine tuning of the teaching of how to use the

> pouch/tool to prolong satiety is not probably able to be

accomplished

> until the patient redevelops hunger before the next meal, in the

> sixth to twelfth month postoperatively. Techniques on delaying the

> return of hunger are simply not relevant to most patients when they

> are not hungry at all, as they are not in the first six months.

Even

> emphasizing preoperatively the crucial need for long term follow up

> care does not always result in patients returning as they should,

but

> one must set the expectation for those who will be compliant for

long

> term follow up.

>

> PREVENTION OF VOMITING

>

> We believe strongly in the principle that vomiting should be

> prevented if at all possible. This teaching begins in the hospital

on

> the second postoperative day when we initially instruct the

patients

> to drink only out of one ounce cups, and to drink only one-third of

> that ounce at a time with sufficient time between thirds to detect

> fullness. We emphasize that it is not easy to get used to having a

> small pouch volume. For the first few months, the patient's mouth

> will be larger than their stomach, a situation which otherwise does

> not exist in the mammalian kingdom. Also, we keep our standard

> gastric bypass patients with their small edematous outlet on liquid

> feedings for the first six weeks, gradually advancing from totally

> liquid nutrition such as

> Ensure supplemented by protein powder up through a blenderized diet

> and very soft solids. The banded gastroplasty/distal gastric bypass

> procedure with its relatively generous 7.0 cm band on its outlet is

> advanced more quickly to soft solid foods by three weeks.

> Vomiting seldom occurs in the immediate postoperative period unless

> there is an outlet obstruction problem. However, vomiting can occur

> and will do so in most patients at some time after starting on

solid

> food. There are more complexities when eating solid food especially

> rice, pasta, or granola, foods that swell in the stomach after

being

> eaten because they are generally incompletely rehydrated before

being

> consumed. The most frequent cause of vomiting is overloading the

> pouch. We encourage patients to continue to measure their meals

with

> their one ounce cups for weeks, even months, following the surgery

if

> they are experiencing difficulty with vomiting. We emphasize

> repeatedly that they should eat only until " comfortably satisfied "

as

> the word " full " has different meanings to different persons.

>

> SIX WEEKS

>

> Solid food is begun with emphasis on the fine cutting of fibrous

food

> to the size of the fifth fingernail or smaller, thoroughly chewing,

> three or more foods at each meal to prevent wadding up of similar

> fibers, eating only until " comfortably satisfied, " and beginning,

> even at this early date, to teach the concept of no liquids with

> meals for fifteen minutes before meals and for one and a half hours

> after meals.

>

> REASSURANCE OF ADEQUATE NUTRITION

>

> Many patients need reassurance that they can achieve adequate

> nutrition in the postoperative period. Without this reassurance,

some

> patients will deliberately eat six to eight times a day because of

a

> fear of malnutrition (often initiated by well meaning family

members

> and friends). We like to point out that in this short period of

time

> during the pouch growth, there are only two major nutritional

needs:

> protein on the one hand and vitamins and minerals on the other. The

> latter can easily be achieved by the patients routine twice a day

use

> of the vitamin supplements. Therefore, their only responsibility

and

> focus is to eat low-fat, animal-source protein at each meal, three

to

> four times a day. If they do this or simply come close to doing

this,

> they will end their first year post-op with a lower than pre-op

lean

> body mass but one that is appropriate to their body weight at that

> time.

> (reference 4)

>

> MEAL SKIPPING

>

> On the other hand, some patients are likely to skip meals when they

> have no appetite, similar to their behavior previously when their

> appetite has been diminished by over tiredness or illness. We

> emphasize the need for three to four meals a day, including

> breakfast, primarily to meet their needs for protein. We emphasize

> that one-half or more of each meal should be composed of this low-

> fat, animal-source protein (two-thirds of their meal in the distal

> gastric bypass procedures) in the first months until their pouch

> volume is large enough so that they can eat at least two ounces of

> protein at each meal.

>

> ARTIFICIAL SWEETENERS:

>

> We warn our patients to be aware of using artificial sweeteners if

> they are experiencing hunger in this early p.o. period. We have

> evaluated a few patients who experienced very strong hunger

cravings

> in the first weeks or months post-op whose hunger abruptly ceased

> with stopping artificial sweeteners.

>

> AVOIDING ABSOLUTES

>

> There are so many rules that we teach concerning the use of

> the " pouch/tool " that we believe that it is important to emphasize

to

> the patient that it is not necessary to follow every rule all of

the

> time. We actually suggest that it is perfectly all right to break

the

> rules once in a while- the important thing is to be aware that one

is

> breaking the rule and having a reason for it even if that reason is

> simply alleviating frustration. We point out that the only penalty

> for eating a liquidy meal when appetite has returned is the earlier

> return of hunger in the next four to five hour period. There is no

> lasting effect beyond that next meal. We also point out that

deciding

> to take advantage of a social opportunity to eat a high calorie,

> empty calorie meal is the ingestion of a relatively insignificant

600

> to 1,000 calories instead of the 3,000 to 5,000 calories that could

> be consumed in such a meal with a normal stomach volume.

>

> THREE MONTHS

>

> At three months we step up the teaching of the nutritional or

protein-

> containing value of foods related to the " cost " of that protein

food

> in terms of calories consumed, i.e. a gram of cottage cheese

> protein " costs " only five calories, but a gram of cheddar cheese

> protein costs sixteen calories, and peanut butter twenty-four

> calories. Water loading techniques (see below) are introduced at

> three months postoperatively as some patients will begin to see a

> return of appetite before their six month office visit. Overall

fluid

> management is discussed, emphasizing how the Gastric Emptying Test

> illustrates the principles of fluid management (see below).

>

> THREE PRINCIPLES FOR GAINING AND MAINTAINING SATIETY

>

> 1. The pouch needs to be truly filled with adequate wall distention

> with each meal (i.e. no snacking).

>

> 2. Keep the pouch filled over time and slow down the emptying time

> (by eating solid foods and avoiding liquids for fifteen minutes

> before and one and one half to two hours after eating. We

understand

> this to be the most important lifestyle change after the gastric

> bypass procedure. Figure 3 shows the results of a standard gastric

> emptying test using radioactive sulfur with a scrambled egg, bread,

> and milk. With the milk, 90% of the meal volume has exited the

> stomach within forty-five minutes. However, without the milk, only

> 45% of the meal has exited the stomach by ninety minutes.

>

> 3. Finally, adequate protein with each meal. We emphasize three

meals

> a day including breakfast (defined as the first meal of the day

which

> is eaten within one to two hours after arising). We define

> the " enemy " as high calorie liquids. We point out that snacking and

> high calorie liquids cheat the patient because the calories are

taken

> in without offering significant satiety.

>

> FLUID LOADING

>

> Fluid loading is the rapid drinking of a non-calorie or low-calorie

> liquid on an empty stomach in order to achieve a maximal intake of

> water at that time and/or achieve immediate satiety which lasts for

> fifteen to twenty-five minutes. About 80% of the estimated maximum

> capacity at any given time should be drunk rapidly over fifteen to

> thirty seconds and then topped off with swallows until full satiety

> is reached. Patients rather rapidly determine what their capacity

is,

> and it usually is between eight to twelve ounces when the Cottage

> Cheese Test volume is four to six ounces. The fluids should not be

so

> cold as to be uncomfortable, but it is not necessary to be warm.

The

> mechanism of action is presumed to be the distention of the Roux

limb

> with subsequent contraction, stopping the progression of fluid

> downwards and backing up the volume and pressure into the small

pouch

> and, perhaps, even into the distal esophagus. Fluid loading works

> with the banded gastroplasty as well but not quite as effectively.

> The mechanism here is probably primary distention of the pouch with

a

> fluid as it is passing through. The volume required is usually

> somewhat greater, but it still is far less than two to four glasses

> of water required in a normal sized stomach. Clearly, this small

> proximal pouch is quite sensitive to distention, and the satiety

> gained from that distention lasts far longer than the distention

> itself. We teach patients to fluid load before each meal in order

to

> help prevent post meal thirst, but also to fluid load whenever they

> feel the sensation of hunger and are tempted to snack.

>

> POST PRANDIAL THIRST:

>

> It is important that the patient be fully hydrated before coming to

> the next meal because the solute load of the meal will create

> postprandial thirst. It seems intuitive that persons cannot

tolerate

> thirst any more than they can tolerate hunger over the long run as

> both hunger and thirst are primary noxious stimuli. Initially, when

> the functional pouch volume is quite small, the solute load is

> correspondingly small, and the patient may not see the point of

> adequate rehydration and pre-meal fluid loading. However, as the

> pouch volume increases and the solute load increases, it becomes a

> significant issue in maintaining that important proscription of

> avoiding liquids during and for an hour and a half after the meal.

>

> URGENCY

>

> In these first months we like to emphasize to patients that their

> golden opportunity for maximizing their weight loss is in the first

> six months after surgery. We illustrate this with the weight loss

> curve, with its rapid downward sweep, with two-thirds of their

weight

> being lost in the first six months postoperatively. The Cottage

> Cheese Test shows that two-thirds of the pouch growth occurs in the

> first six months. Therefore, we teach our patients that every day

> during this early period the exercise and activity that they do

will

> be more effective in burning calories in excess of their calorie

> intake than the same amount of activity/exercise the following

> day. . . and a little less effective than the previous day based on

> progressive pouch growth. I.e. every single day the patient should

> take advantage of their present opportunity and get as much

activity

> as they can, knowing that never again will that same amount of

> activity result in as much weight loss. We try to give them a sense

> of urgency about getting the most out of every day.

>

> SIX MONTHS

>

> At this point, or soon after, our patients are beginning to get

> hungry before their next meal, and we accelerate the teaching of

> satiety mechanisms and the prevention of post meal thirst. As the

> meal solute volume increases, they need to push enough fluids in

the

> two to three hours before the meal to gain good hydration with

final

> water loading fifteen minutes before the next meal.

>

> INTAKE INFORMATION SHEET AS A TEACHING TOOL

>

> At each visit from three months to two years, the patient is asked

to

> complete a form before they come into the office. The form queries

> them about their performance on the principles of pouch use (as

well

> as vitamin usage, exercise, pathological symptoms, etc.). This form

> is designed so that it is also a teaching tool- each question

reminds

> the patient about the principles of the use of their pouch/tool.

> Many, if not most, patients do very well, and their weight loss is

> progressive and satisfying. Some struggle to make the lifestyle

> changes necessary, but with these periods of intermittent

monitoring,

> encouragement, and teaching they progressively learn and most do

> well. A few patients never seem to understand or to remember these

> simple principles even though they might be quite intelligent,

> capable persons in other facets of their lives. . .

>

> HONEYMOON SYNDROME

>

> The profound satiety that patients experience in the first six

> months, along with the rapid weight loss due to intake restriction,

> can lead certain patients to believing that these circumstances

will

> never change in spite of the clear teaching of our patient

> information booklet and clinic visit handouts. For these patients,

we

> will then see a slackening off on their food selection and liquid

> calorie control and see them indulge in more recreational eating.

> They will cut back on their exercise as they seem to be losing a

> great deal of weight without exercising. Their weight loss will

> subsequently slow. We have dubbed this situation the " honeymoon

> syndrome " and tried to educate our patients, even in our

preoperative

> informational booklet, that they can expect this temptation to

occur

> and that they must not get " suckered " into a false sense of comfort

> that leads them to not make a sufficient effort in their own behalf

> and miss this golden opportunity for weight loss. We have found

that

> an effective tool for identifying and reality-orienting the patient

> is to graphically compare that patient's weight with the mean

weight

> loss of the group as a whole. Whatever the patients beginning

weight

> is, we would expect them to parallel the weight loss curve. If

their

> weight deviates from the expected, we should be able to find a

reason

> for it and to correct it if the patient is willing to learn and

make

> this needed lifestyle change.

>

> EXERCISE

>

> Although this chapter is about understanding the function of the

> small proximal gastric pouch and how it relates to patient

> management, a word must be mentioned about exercise. We believe

that

> the scientific data overwhelmingly demonstrates that 1) exercise is

a

> critical part of a healthy lifestyle for patient and doctor alike,

> and 2) that exercise is necessary to maintain weight loss in the

> obese patient. Therefore we believe it must be a critical part of

our

> postoperative patient teaching and encouragement. Exact details are

> beyond the scope of this presentation, but we do emphasize to the

> patients that the feelings of vigor and energy are in no way

> guaranteed by a slender figure. Observations of people on any city

> street confirm this. . . We emphasize that the release of

endorphins

> with aerobic exercise improves emotional stability and mental

clarity

> and helps any person to cope with the deprivations and annoyances

of

> everyday life. Endorphins, adrenalin, norepinephrine, etc., also

act

> in an antidepressive manner. But most importantly, especially in

the

> first six month period when the gastric pouch is so small, regular

> aerobic exercise maintains, or even improves basal metabolic rate

> that is observed to drop during rapid weight loss.

>

> THE IDEAL MEAL FOR WEIGHT LOSS

>

> The ideal meal for weight loss is one-half of the meal volume up to

a

> total volume of two to three ounces of animal-source, low-fat

protein

> plus filling the rest of the pouch volume with low starch

vegetables

> and solid type fruits such as apples and pears. Cut finely and

chewed

> well, these foods represent coarse, solid food choices that are

> likely to stay in the pouch longer and offer good nutritional

value.

>

> VOLUME VERSUS CALORIES

>

> A person with a normal stomach tends to judge how much he/she needs

> to eat at a given meal by approximately how many calories are in

that

> meal (although not necessarily thinking of calories as such). In

> other words, we know that we are going to be unpleasantly hungry

> before dinner if our noon meal consists of a green salad and a

couple

> of ounces of cottage cheese. Calories are what keep us from getting

> hungry between meals. On the other hand, the post-op gastric bypass

> patient needs to learn to think about the volume and consistency of

> food choices rather than their caloric content when judging how to

> prevent getting hungry before the next meal. I recall a lecture I

> once attended in which the lecturer pointed out that one or two

> sticks of butter could meet our entire calorie needs for the day

and

> could be easily consumed by even the small post-op gastric bypass

> pouch. However, that same number of calories in the form of non-

> starchy raw vegetables could not be consumed by a person with a

> normal stomach in only three meals a day. There is an enormous

> variation between calories and volume, and a patient needs to learn

> how to " think volume " when making food choices to gain and maintain

> satiety in a mature small gastric pouch.

>

> ISSUES FOR LONG TERM WEIGHT MAINTENANCE

>

> The previous comments are primarily designed to deal with patient

> issues in the first year following a gastric bypass procedure.

These

> issues should seamlessly slide into long term weight maintenance

and,

> indeed they do so in most persons.

>

> COUNTER-INTUITIVENESS OF FLUID MANAGEMENT:

>

> It is clear that avoiding liquids with meals and pushing fluids

> between meals is counter intuitive. The large capacitance of a

normal

> stomach is a great convenience factor for that person and, truly,

all

> animal life. There is a resistance to learning this technique, and

> clearly it is counter intuitive to the experience of the

individual.

> However, if it is important that solid food be taken rather than

> liquidy food to maintain satiety, then it is clearly important to

> avoid liquids with meals or soon after meals as the liquid will

> simply make the food more soup-like and soft and allow more rapid

> emptying of the pouch and, therefore, shorten the period of

satiety.

>

> SUPPORT GROUPS

>

> We have found that support groups are very effective in reinforcing

> the principles of the pouch/tool use. Many, if not most, patients

> will explore these principles on their own by using them and then

for

> a time not using them. Some patients on their own become convinced

of

> the value of these principles through this natural experimentation.

> However, others may lose their way. The support group offers an

> excellent feedback mechanism for individuals who need reinforcement

> of the principles of the pouch use. Sometimes, the feedback of

their

> peers is more effective than that of the parental figures in the

> surgeon's office.

>

> TEETER-TOTTER EFFECT

>

> One " visual " that we use when discussing weight maintenance is that

> of a teeter-totter. On one end of the teeter-totter is the

> exercise/physical activities, and on the other end is the meal

choice

> discipline and fluid restrictions. When one has a large amount of

> exercise and activities, the teeter-totter swings down on that end,

> and the amount of effort that need be placed on diet discipline

> lightens up. When one is light on the activity/exercise, one has to

> be much heavier on the diet discipline side. If one is light on

both

> exercise and diet discipline, the whole teeter-totter moves upward

as

> weight is gained. On the other hand, if one is " heavy " on both

> exercise and diet discipline, the teeter-totter bar goes down, and

> weight is lost.

>

> TOO MUCH WEIGHT LOSS

>

> There are a group of patients in our practice, approaching 15%, who

> lose too much weight in the one to two year period postoperatively.

> Inevitably, these individuals were only 100 to 150 pounds

overweight

> to start with and are good exercisers. We encouraged them to taper

> off their efforts with diet discipline (maintaining their exercise

> routine and thus their vigor) by adding some fat back to their

meals

> and eating a fourth or fifth meal a day with less discipline on the

> fluid management. Basically, it is an exercise on " how to beat the

> pouch. " The pouch can be beaten by one, liquid high calorie meals;

> two, frequent meals or grazing; three, eating a meal over thirty to

> forty-five minutes; four, adding liquid to meals to enhance gastric

> emptying; five, liquids are taken shortly after eating which

> increases gastric emptying and decreases the satiety period. Some

> patients take our advice and taper off their weight loss before

they

> go underweight. However, a small but significant group of patients

> actually go underweight because all of our patients have

experienced

> the rapid and frightening return of severe hunger cravings when

going

> from one of their many diets to trying to eat normally once again.

> Very similar to a bear coming out of hibernation, their suppressed

> appetite center seems to burst out with vigor in order to save the

> life of this person who the appetite center sees as a normal weight

> person having suffered in a famine. Many patients at this point

have

> not yet fully accepted that they have had a true anatomic and

> physiologic change from their operation and that, using the

> principles of the pouch/tool, a return of this overwhelming

appetite

> will not occur. For these persons, it is not until their lean body

> mass is effected and they lose their delightful sense of vigor that

> they will begin to " break the rules " and gain some needed weight

> back. This is probably the primary reason why, in most bariatric

> surgical practices, the weight loss curve bottoms out at eighteen

to

> twenty-four months with a rise at two to three years. This rise has

> been erroneously interpreted as most patients regaining 10% to 15%

of

> weight from the nadir of their weight loss.

>

> BARIATRIC MEDICINE

>

> A much more common problem is that of patients who have not lost as

> much weight as they would like and are plateauing at a level above

> their goal weight. Bariatric medicine techniques can be useful in

> helping our postoperative patients who find themselves stuck on a

> plateau one or more years postoperatively. However, there can be a

> problem with standard weight control and dietary teaching of

> Bariatric medicine. The frequently used recommendations of frequent

> small feedings or liquid calorie fasts such as a protein sparing

> modified fast, neutralizes the satiety function of the pouch/tool,

> and tends to negate the teachings of the principles of the pouch

use,

> and therefore is probably not an optimum way of managing the

patient.

>

> SUMMARY

>

> The principles of the postoperative bariatric surgical follow up

> management are as follows:

> 1. Understanding the fundamentals of the anatomy and physiology of

> the pouch/tool.

> 2. Evaluating the patient's appropriate or inappropriate use of the

> tool- What is lacking? What is being done well?

> 3. Instruct patient with words, drawings, analogies, encouragement,

> and passion, on not only what to do but why it needs to be done.

>

> The goal is to make the patient become fully knowledgeable about

how

> to control their own weight over the long term through the

> appropriate use of their pouch/tool, combined with a reasonable

> amount of exercise.

>

> EVALUATION FOR WEIGHT LOSS FAILURE

>

> Evaluating a patient who is progressively regaining weight can be

> relatively simple- or extremely difficult. The first principle is

to

> determine that the gastric pouch is anatomically intact. If it is

not

> intact, it should be made intact by a revision procedure. Only when

> the surgeon can be reassured that the pouch is intact does the

> complex part begin- evaluating how and why the patient is not using

> the pouch/tool properly, and/or getting a reasonable amount of

> exercise.

>

> We need to know three things about the small gastric pouch. First,

is

> the staple line intact; second, is the outlet intact; and third, is

> the pouch reasonably small in size.

>

> The upper GI series with thick barium is the basic tool for

> evaluating intactness of the staple line and the outlet. If the

pouch

> has been stapled in continuity with the rest of the stomach, we

must

> confirm that the staple line remains intact. An eventration of the

> staple line will create two gastric outlets leading to rapid pouch

> emptying, early loss of satiety, and thus early return of hunger.

An

> important clue from the patient's history is the presence of a

> marginal ulcer after a gastric bypass. Marginal ulcers do occur,

> occasionally, with an intact staple line. However, they are more

> common with a small hole in the staple line that results in food

> stimulation of the antrum. If there is a staple line eventration,

the

> marginal ulcer is unlikely to be able to be controlled without

> reoperation and closure of that eventration, preferably with

complete

> division of the small pouch from the distal stomach.

>

> The upper GI series with thick barium in the hands of an

experienced

> radiographer can usually give the bariatric surgeon a reliable view

> of the diameter of the gastric outlet. A diameter of over 18-20

> millimeters is usually associated with weight regain, and we term

> this " outlet failure. " Outlet failure, like a staple line

> eventration, causes rapid emptying of the pouch, early loss of

> satiety, and early return of hunger.

>

> On the other hand, weight regain can occur as a result of an outlet

> diameter under 7-8 millimeters which can lead to persistent

vomiting

> of solid foods and gradual persuasion of the patient towards the

Soft

> Calorie Syndrome with resultant rapid pouch emptying, early loss of

> satiety, early return of hunger, and weight regain.

>

> The upper GI series is less effective for evaluating pouch volume

> because of the fact that barium is very much of a liquid. To assess

> pouch volume, you must turn to the patient's history of the size of

> the meal that he/she can consume within a short five to fifteen

> minute time frame, and/or to the Cottage Cheese Test (see above).

>

> In the patient whose gastric pouch seems to be anatomically intact

> and yet he/she is still regaining weight, the evaluation becomes

more

> complex. The usual finding is that the patient is not following the

> principles of the use of their pouch/tool and/or is extremely

> inactive physically. There are four problems that occur with some

> frequency: the patient has never been taught/or does not understand

> how to use the tool; the patient is significantly depressed; or

loss

> of contact with a bariatric practice and other bariatric patients

and

> a gradual erosion of following the principles; or the patient is

> truly noncompliant and will not take responsibility for his/her own

> behavior.

>

> LACK OF TEACHING

>

> An excellent example of the lack of teaching/understanding of how

the

> pouch works is found in the history of GC. GC is a 62-year-old

woman

> who presented in consultation for a total regain of her weight and

> complaint of constant hunger, sixteen years following a gastric

> bypass procedure in Cambridge, Massachusetts. She stated that she

had

> not seen the surgeon beyond the six week follow up visit. She

> understood nothing about how to use her gastric pouch. She

initially

> lost fifty pounds and then another forty pounds further with the

help

> of a commercial weight management program. For the next ten years

she

> yo-yoed up and down with the usual peer group and doctor supported

> programs with a gradual increase in weight and the usual hunger and

> deprivation syndromes relating to these programs. She then

developed

> myasthenia gravis and her weight regain escalated to her

preoperative

> weight, resulting in the referral. At the time of the referral she

> was being treated effectively for myasthenia gravis and was

> reasonably active, being able to walk over a mile at a time. Her

> weight loss curve with its abrupt turn around and rapid weight loss

> (figure 4) could be consistent with a revision reoperation.

However,

> there was no revision done. After evaluation of her pouch/tool with

> an upper GI series and a Cottage Cheese Test/functional meal volume

> estimation, she was given the basic instructions of how to use her

> pouch/tool, the same given to all of our postoperative patients.

Her

> ensuing and continuing weight loss is impressive, but more

impressive

> to the patient is that she is not experiencing any distressing

hunger

> cravings, food fantasies, or food dreams as she had experienced

with

> all of her previous efforts, since the first months after her

gastric

> bypass procedure sixteen years ago.

>

> DEPRESSION

>

> Depression is a powerful inhibiter of success after bariatric

> surgical procedures. A small but significant number of our patients

> have been doing well following their gastric bypass procedure only

to

> drop out of sight for a time and then reappear with a significant

> weight regain. Upon evaluating these patients, it would appear that

> in many instances they seemingly deliberately reverse all of their

> learned principles of the use of their pouch/tool: grazing and

> snacking through much of the day, drinking high calorie liquids,

> drinking liquids with meals, and stopping their exercise, even when

> they are intellectually aware that exercise in itself releases

> numerous vasoactive substances which act like antidepressants. DB

is

> a 46-year-old woman who had an excellent initial weight loss

> following a gastric bypass procedure (figure 5). While still in the

> first year after her gastric bypass, her life, already made

difficult

> by divorce and economic circumstances, became severely disrupted

when

> her only daughter developed a drug problem, an abusive

relationship,

> and finally HIV, and was forced to give up her newborn child. Her

> weight regain was dramatic. However, even more dramatic was her

> weight loss once her depression eased, and she was able to look

after

> herself once again. She relates that she did nothing dramatic such

as

> fasting. She simply returned to using her pouch/tool in the manner

in

> which she had been taught and resumed a moderate exercise program.

> What can the bariatric surgeon do when patients are obviously

> depressed and regaining weight? Obviously, the most important thing

> is to steer them to professional counseling, if they are not

already

> in counseling. Then, the surgeon can be encouraging. We can

encourage

> them to continue to use the tool as best as they can; we can

> encourage them to return to exercise which will improve the spirits

> and reassure them that the improvement is " deserved, " " because you

> really are a good person, and you deserve to feel better. . . " Most

> of all, the surgeon can reassure them that the pouch/tool is not

> ruined by this overeating and gradual weight regain if it does not

> result in persistent vomiting of solids. When they are ready once

> again to use their pouch/tool, it will be there for them, and they

> will be able to once again lose weight without being hungry.

>

> EROSION OF THE USE OF THE PRINCIPLES:

>

> In a third subset of weight maintenance failure patients, a subtle

> weight creep can occur to patients who are otherwise compliant, non-

> depressed, and have intact pouches. The patient will see it

> as " struggling " with his/her weight, and by definition, he/she will

> not have seen you in follow up and will have usually lost contact

> with the support group or other bariatric surgical patients. There

> seems to be a progressive erosion of following the principles of

the

> pouch/tool use. This may be due to denial as seen in diabetic

> patients, or it may be due to the influence of their peer group and

> the fact that some of the principles of the use of the pouch/tool,

> especially fluid management, are counter- intuitive and counter to

> behavior of their peer group. The patient will often not come back

> for evaluation because " I know what I'm doing wrong! " (meaning that

> he/she is eating the wrong things and too often), and these

patients

> will internalize their " failure " with an increasing sense of guilt

> which itself acts as an inhibition to coming back to their

surgeon's

> office for help.

> From the beginning, in our preoperative teaching, we emphasize the

> possible need for a " refresher course " in the use of the principles

> of the pouch/tool at some time in the future. Some patients still

do

> not return. The trick is identifying these patients and somehow

> getting them back either into the office or into a support group.

> In these three examples- lack of teaching, depression, and gradual

> erosion of the use of their tool, weight once regained can be lost

> once again if the pouch is anatomically intact and the patient

> decides to use it, or learns how to use it or relearns how to use

it.

> In these three examples, we are working with compliant, reasonably

> responsible persons who, when they can, are willing to take

> responsibility for their own behavior.

>

> TRUE NON COMPLIANCE:

>

> The most difficult problem is determining, and being comfortable

with

> that determination, when a patient is being fundamentally

> noncompliant and obstructive. This type of individual may leave

your

> care and go to others complaining about a " personality conflict, "

or

> perhaps even that you have not given them the time and attention

that

> they need and deserve. Inexplicably, some will actually stay in

your

> care. In this instance, when the patient tends to return perhaps

even

> more frequently than usual, depression will be more likely the

> underlying mechanism rather than noncompliance. It can be difficult

> to be reasonably sure of what is going on in one or two visits. The

> truly noncompliant patient will very likely end up with multiple

> revisions and/or a reversal due to weight regain or complications.

> This kind of patient is often quite resistant to counseling, but I

> know of no other management option that offers much hope for

success.

> Luckily, this type of patient represents a very small minority of

our

> patients. Obviously, prevention in the form of patient selection is

> better than cure, but after twenty-three years of a bariatric

> surgical practice, I have yet to be able to effectively identify

> these persons preoperatively. I have, in fact, suspected

significant

> noncompliance in a number of my patients who have turned out to be

> quite compliant particularly after control of other problems, such

as

> sleep apnea, that effect understanding and complying with our

> instructions. With the current lack of an effective psychological

> screening tool to reliably identify these individuals, I tend to

lean

> towards giving each person a chance at a good and healthy life

> provided by bariatric surgery.

>

> BIBLIOGRAPHY

> 1) Mason, EE, Personal Communication, 1980

> 2) Barber, W, Diet al, Brain Stem Response To Phasic Gastric

> Distention. Am J. Physiol 1983; 245(2): G242-8

> 3) Flanagan, L. Measurement of Functional Pouch Volume Following

the

> Gastric Bypass Procedure. Ob Surg 1996; 6:38-43

> 4) Rosemurgy, A.

>

>

>

>

>

>

>

>

>

[Guest guest]

I agree. As time passes Dr. R will find more things that need to be included.

This is a learning curve for him, too, I am sure.

Pat

Re: Drinking/thirsty

---

What a great article... I have been putting some of those principles

to use and have broken my plateau and lost 4lbs YAY I am eating

much more protien, and really working on fluid loading and the

hardest ting is working on drinking BEFORE MEALS... I was drinking

with meals, not much, but some, and now I won't be doing that any

more.. I found especially interesting the part where the woman had

regained her weight over the 16 years and by using these principles

was able to lose weight again, since according to thise article I am

done with the honeymoon stage, which I had already figured out..and

the larger amounts of protien makes me feel full longer and works

well.This article should be part of the clos.net site for all post-

ops it really stresses proper managment of the " tool " .

Suzanne

1.10.01

-64

In @y..., " wwmohler " <wwmohler@s...> wrote:

> Here is an article that might shed some light on the drinking etc.

with meals along with some other information. Now although it was

not written by our beloved Dr. R, (Dr. R feel free to chime in, maybe

he even knows the Dr. that wrote this,) there is some information I

have found useful.

>

> POST-OP TEACHING AND EVALUATION

>

> By Latham Flanagan, Jr., M.D., FACS

>

> Article is sectioned by capitalized categories.

>

> INTRODUCTION

>

> >From our earliest experiences in bariatric surgery, we have been

> intrigued with the question " How does our operation cause weight

loss

> and maintenance? " As we talked to the public, and even our medical

> peers, it became evident that a common concept of the uninformed is

> that the small gastric pouch simply mechanically restricts intake,

> preventing the post-op patient from eating too much. Indeed,

> superficially, it may appear that way especially in the first 3-9

> months post-op. However, even a short experience with following our

> patients shows us that with a meal size of even three to five

ounces,

> certain patients will stop losing weight and start to regain. We

also

> note that two to five or more years postoperatively certain

patients

> seem to have a large meal volume of six to ten ounces but still

> maintain good weight control without an noxious degree of hunger.

It

> has become clear with experience that the principle of weight

control

> is the achievement of satiety, or the absence of abnormal hunger,

> associated with the ingestion of the appropriate number of calories

> sufficient to meet the person's need. If adequate satiety is

> achieved, our patients are successful. . . And they fail if that

> satiety is not achieved. When patients " fail " there is a tendency,

> even among bariatric surgeons, to pass it off as " noncompliance. "

> Certainly, this can be an appropriate evaluation in a few persons

who

> are not willing to accept responsibility for the lifestyle changes

> necessary to make the small gastric pouch function properly. But,

is

> this the problem for the majority? I think not. When failure does

> occur, it is usually the inability to maintain the post meal

satiety

> long enough to prevent snacking before the next meal time arrives.

> Also, it could be due to ingestion of a large number of calories in

a

> form that is somewhat hidden to the patient and is not responsive

to

> the gastric pouch restriction, especially high calorie liquids.

>

> HYPOTHESES OF POUCH FUNCTION:

>

> At this point in time what have we learned about how the small

> gastric pouch works? In the form of an hypothesis, we can now state

> that the basic mechanism is that of stretch of the pouch walls with

> eating of a small meal, or even the drinking of fluid. This stretch

> is sensed by the stretch receptors in the pouch wall and relayed by

> neural pathways to the appetite centers in the hypothalamus by way

of

> the tractus and nucleus solitarius. The second hypothesis is that

> successful maintenance of satiety depends upon the creation and

> maintenance of a small gastric pouch and a small gastric pouch

outlet

> (Mason- reference 1). The third hypothesis is that the observed

> increase in functional meal volume over the months and years

> following a gastric bypass procedure is due to the process of

> hyperplasia and is not wholly or in great part due to noncompliance

> on the part of the patient. The fourth hypothesis is that

> understanding of these principles and effective teaching to a

> compliant patient results in better weight loss and maintenance

than

> if the teaching is not accomplished.

>

> PUBLISHED DATA

>

> To support these four hypotheses, we have two pieces of reasonably

> good scientific information from peer reviewed published articles.

> From that point we must rely on observational-based science.

>

> Our first question is how does the small gastric pouch create

> satiety? Considerable insight on the neurological pathways of

satiety

> has been obtained through the work of Barber, a Ph.D.

> veterinarian, and his associates who published a paper in 1983

> entitled " Brain Stem Response to Phasic Gastric Distention. "

> (reference 2) They placed a balloon in the stomachs of anesthetized

> cats and surrounded the stomach with a strain gauge.

Microelectrodes

> were placed in the nucleus and tractus solitarius of the brain

stem.

> They found a population of neurons that faithfully monitor moment

to

> moment changes in gastric wall tension. The discharge frequency to

> wall tension did not adapt for the twelve hour period of the

> experiment. This response was dependent upon an intact vagal nerve

in

> these cats. They concluded that " these neurons may serve as a

> critical link between the stomach and higher centers in the

conscious

> perceptions of fullness. " It seems particularly impressive and

> interesting that the neurons continued to fire at an accelerated

rate

> for as long as twelve hours, if the gastric wall tension remained

> high.

>

> Another question of considerable importance to the thinking of a

> bariatric surgeon is what is the fate of the small gastric pouch?

> Does it enlarge at all after the surgical procedure? If it does

> enlarge, is it because the operation was done improperly? Was it

> because of gross patient noncompliance and gorging? Or, is it due

to

> the kind of hyperplasia seen throughout the gastrointestinal tract,

a

> response to loss of function? Dr. E. E. Mason, at one of the Iowa

> Bariatric Symposia in the early 1980's, suggested that it might be

> useful to ask patients to eat cottage cheese in a structured manner

> in order to attempt to determine their functional meal volume at

> different times postoperatively. I took the idea home and began

> asking all of my patients to do this simple test with each one of

> their follow-up postoperative visits at three, six, nine, twelve,

> eighteen, and twenty-four months. We continued to do this over the

> next decade (and subsequently to date), and figure 1 reveals a

> regular, progressive, stepwise increase in functional pouch volume

> over time that strongly suggests the orderly process of

hyperplasia.

> Stabilization occurred at two years at a mean pouch size of six

> ounces with a wide range of three to nine-ten ounces. The pouch

> appears to not get larger after the second year. (reference 3)

These

> gastric bypass pouches were created as a vertically oriented, 30 cc

> pouch measured against both volume and pressure of 70 to 85 cm of

> water. The curve of pouch enlargement is the inverse of the weight

> loss curve.

>

> We then proceeded to compare the patients' weight losses at one and

> three years to pouch sizes at one year. Figure two reveals that

there

> was no difference in percent excess weight loss at one year, with

the

> different pouch sizes within this range of up to nine-ten ounces.

We

> then compared the largest third of pouch sizes to the smallest

third

> of pouch sizes, and still there was no significant difference in

> weight loss at one year or of maintenance at three years. This

> finding is, perhaps, the most important result to come from the

> Cottage Cheese Test work. It strongly suggests that within these

> limits of pouch sizes that success in weight loss and maintenance

> depends not only on having a small gastric pouch but even more so

in

> how the patient uses their " pouch/tool. " If this is true, then the

> implication is clear that learning how to use the pouch/tool

> effectively is important and that it is our responsibility as

> bariatric surgeons to see that effective teaching is made available

> to our patients over this two year period of changing intake and

> satiety control. In brief, the Cottage Cheese Test data tells us

that

> within the context of a small meal volume, lifestyle change

including

> exercise is the most important variable. The stepwise progressive

> growth in the functional pouch volume (meal size) probably defines

> the rate of weight loss for the patients taken as a whole, but the

> degree of weight loss and maintenance for the individual patient is

> more dependent upon that patient's ability to make the required

> lifestyle changes: proper use of the pouch/tool and adequate

amounts

> of activity and exercise.

>

> OBSERVATIONAL-BASED MEDICINE

>

> Observational-based medicine has a long history of respect going

back

> to the early work of two of my personal surgical heros, s

> Vesalius and Ambrose Paré. Indeed, we often refer to the " art and

> craft of surgery " . Although we do make great effort to have a

> scientific basis to our surgical decision making, ideally with

> prospective randomized studies or double blinded studies, at this

> point in time the majority of what we do is based on empiricism, or

> observational-based medicine. The observations that I would now

like

> to share from my own personal thirty-three years of experience in

> bariatric surgery are also shared by many other experienced

bariatric

> surgeons of my acquaintance, although not all would agree with all

of

> these principles.

>

> For the first fifteen years, although I remained busy in a general

> surgical practice, my primary interest, bariatric surgery, lagged

> because of the lack of patient material, primarily because of the

> profound discrimination of medical insurers against the morbidly

> obese in our area of the country. What appeared to be a

disadvantage

> initially became an advantage, as I thereby had the opportunity to

> follow almost all of my patients personally during that time. As

> there was little known about the mechanism of action of the gastric

> bypass procedure, I spent a good deal of my time thinking about

> possible mechanisms and observing the differences between patients

> with good weight loss and those with poor weight loss. Since the

> beginning, I have performed the short limb gastric bypass procedure

> (GBP), only adding the malabsorption procedure of the banded

> gastroplasty/distal gastric bypass procedure (BG/DGB) in 1992. The

> BG/DGB also uses a small, vertically oriented gastric pouch quite

> similar to the gastric bypass procedure pouch, the difference being

> that the outlet is controlled by a band as in the vertical banded

> gastroplasty and silicone ring gastroplasty, etc., instead of a

> gastroenteric anastomosis. My observations seemed to be similar for

> the two procedures, although not identical for both. The Cottage

> Cheese Test was done only with the GBP. Considering the above, what

> do I think that I have learned?

>

> The following are observations that may have an effect on the

> function of the gastric bypass pouch:

>

> 1. We have come to understand that the accomplishment of satiety,

or

> suppression of hunger, is fundamental to the success or failure of

> bariatric operations.

> 2. We have come to understand that success relates anatomically to

> creating a small pouch that remains relatively small and a small

> outlet that remains relatively small (Mason).

> 3. Meal volumes much larger than ten-twelve ounces usually result

in

> failure of weight maintenance.

> 4. The use of the thick, less distensible lesser curve of the

stomach

> is believed to be important by many surgeons.

> 5. Satiety is achieved by increasing the tension on the gastric

pouch

> wall, thus stimulating the stretch receptors.

> 6. Maintaining satiety is dependent upon maintaining some portion

of

> that stretch for an undefined period of time.

> 7. For either the gastric bypass or the banded gastroplasty, almost

> all patients have a profound satiety, 24 hours a day, in the first

> six months or so following their bariatric surgical procedure. They

> do not redevelop a normal appetite preceding the next meal until

six

> to twelve months postoperatively.

> 8. If for any reason the patient is NPO for a significant period of

> time like eight to twelve hours, a profound hunger will be

> experienced.

> 9. In the mature pouch at one plus years post-op, the more solid of

> food that a patient eats, the longer is the satiety period after

the

> meal.

> 10. Almost all patients after the gastric bypass procedure, and

most

> patients after the vertical banded gastroplasty, achieve fifteen to

> twenty-five minutes of satiety after simply rapidly drinking water

to

> a point of fullness, or " water loading. "

> 11. Some patients fail the banded gastroplasties in association

with

> shifting their diets to mostly liquids or soft solids, the " soft

> calorie syndrome, " and they fail by becoming hungry too soon before

> their next meal and giving in to snacking between meals because of

> that hunger.

> 12. Responsible patients who carefully follow the principles of

using

> their " pouch/tool " continue to have a reliable and progressive

weight

> loss and weight maintenance.

> 13. Patients who approach or become underweight at one to two years

> following bariatric surgery can reverse their weight loss with

> reversing the principles of using their pouch/tool.

>

> HOW DO WE INTERPRET THESE OBSERVATIONS?

>

> POUCH SIZE:

>

> It seems intuitive that the functional meal volume must stay small

in

> order to limit the patient's caloric intake and provide satiety.

What

> is not clear is how small it must remain. The Cottage Cheese Test,

> discussed previously, gives us some insight. With the data from

that

> test, the pouch size/functional pouch volume can exceed six to

seven

> ounces and still give as good a satiety as a smaller pouch.

> Obviously, this depends on patient behavior such as choices of

> specific foods eaten, frequency of meals, fluid management, and

last

> but certainly not least, the amount of activity/exercise.

>

> OUTLET SIZE:

>

> The outlet of the small gastric pouch is a fixed ring, either fixed

> by scar or fixed by a band or both. There is no longer a valve that

> controls the rate of emptying. Therefore, it is intuitive that

> liquidy foods will exit the pouch faster than more solid foods.

> Certainly, no pouch can control the amount of fluid consumed, nor

> would it be tolerable if that could be done. Therefore, the

calories

> contained in high calorie liquids have the ability to defeat weight

> loss or maintenance.

>

> EARLY PROFOUND SATIETY:

>

> The mechanism of action of the profound satiety of the first six

> months is presumed to be due to the necessity of the patient

drinking

> water very frequently throughout the day in order to meet minimal

> fluid requirements. From our experience with " water loading, " we

note

> that water loading will give almost all patients fifteen to twenty-

> five minutes of satiety if done when they are hungry. Presumably,

the

> frequency of water drinking during the first six months simply

> overlaps these short periods of water-induced satiety.

> The return of appetite in our patients at about six months

correlates

> with two-thirds of the pouch hyperplasia as determined by the

Cottage

> Cheese Test. The average pouch size then is approximately four

ounces

> when the lesser curve pouch is created at one ounce in volume at 70-

> 85 cm of water pressure. The mechanism of action is presumed to be

a

> less frequent stimulation of stretch receptors in the gastric pouch

> wall because at this point the patient can ordinarily drink six to

> eight ounces of water at a time.

>

> OPTIMUM MATURE POUCH:

>

> How might we describe the optimum mature pouch? The pouch seems to

> work best when one, the outlet is not too restrictive to allow

eating

> of solid foods such as meat and vegetables but two, the outlet is

not

> so large as to allow early emptying and premature loss of satiety

> from solid food, and three, the pouch is not too large to allow

over

> eight-nine ounces a meal.

>

> IDEAL MEAL PROCESS:

>

> What might be the ideal meal process? The ideal meal process

includes

> timing of meals. To get through the day without hunger on three

meals

> a day, there needs to be about five hours between breakfast and

> lunch, lunch and dinner, and dinner and bedtime. It becomes evident

> that if there are only three hours between breakfast and lunch, and

> then six to seven hours between lunch and dinner, that one cannot

> expect satiety to be maintained over the full seven hours, no

matter

> how solid the food eaten, short of frank outlet obstruction. For

the

> optimum meal, a more solid type of food such as finely cut meat and

> minimally cooked or raw vegetables should be eaten. The meal should

> be taken over five to fifteen minutes, depending upon the

functional

> pouch volume. Stringing a meal out over thirty to forty-five

minutes

> or more is one of the techniques that has been used to " beat the

> pouch. " Following the meal, take no liquids for one and a half

hours,

> or even two hours if satiety is lost too soon before the next meal.

> Then, after that one and a half to two hours is up, begin drinking

> low or no calorie fluids somewhat slowly (in order to avoid over

load

> symptoms if there is still considerable food in the pouch) and then

> progressively accelerate drinking up to fifteen minutes before the

> next meal. The patient should be urged to drink a lot of water in

the

> two hours or so before the following meal. This period of

rehydration

> ends with a " fluid load " fifteen minutes before the next meal.

> However, a single pre-meal fluid load can never adequately

rehydrate

> an individual who has not already been drinking a lot of fluid.

Fluid

> loading can be done any time in the two to three hours preceding

the

> meal if hunger is experienced. This use of the fluid load can

> substitute for taking in unwanted calories through snacking.

>

>

>

> THE MANAGEMENT OF PATIENT TEACHING AND TRAINING

>

> Postoperative patient instruction begins with setting appropriate

> expectations preoperatively through the information provided in

your

> thorough patient information booklet. This is the time to introduce

> fundamental principles such as: the small gastric pouch is a " tool "

> to gain and maintain satiety. Most patients have a fairly clear

> picture that a tool is something that one uses to perform a task

but

> that the tool itself is relatively useless if it is put away on a

> shelf and not used. Patients also seem to appreciate that

developing

> skill in using a tool will make the tool more effective.

>

> NECESSITY FOR LONG TERM FOLLOW-UP:

>

> We emphasize the need for long term follow up care. It is not

> possible in most patients to teach a fundamental change in

lifestyle

> in " theory " by written materials given preoperatively or

immediately

> postoperatively. The fine tuning of the teaching of how to use the

> pouch/tool to prolong satiety is not probably able to be

accomplished

> until the patient redevelops hunger before the next meal, in the

> sixth to twelfth month postoperatively. Techniques on delaying the

> return of hunger are simply not relevant to most patients when they

> are not hungry at all, as they are not in the first six months.

Even

> emphasizing preoperatively the crucial need for long term follow up

> care does not always result in patients returning as they should,

but

> one must set the expectation for those who will be compliant for

long

> term follow up.

>

> PREVENTION OF VOMITING

>

> We believe strongly in the principle that vomiting should be

> prevented if at all possible. This teaching begins in the hospital

on

> the second postoperative day when we initially instruct the

patients

> to drink only out of one ounce cups, and to drink only one-third of

> that ounce at a time with sufficient time between thirds to detect

> fullness. We emphasize that it is not easy to get used to having a

> small pouch volume. For the first few months, the patient's mouth

> will be larger than their stomach, a situation which otherwise does

> not exist in the mammalian kingdom. Also, we keep our standard

> gastric bypass patients with their small edematous outlet on liquid

> feedings for the first six weeks, gradually advancing from totally

> liquid nutrition such as

> Ensure supplemented by protein powder up through a blenderized diet

> and very soft solids. The banded gastroplasty/distal gastric bypass

> procedure with its relatively generous 7.0 cm band on its outlet is

> advanced more quickly to soft solid foods by three weeks.

> Vomiting seldom occurs in the immediate postoperative period unless

> there is an outlet obstruction problem. However, vomiting can occur

> and will do so in most patients at some time after starting on

solid

> food. There are more complexities when eating solid food especially

> rice, pasta, or granola, foods that swell in the stomach after

being

> eaten because they are generally incompletely rehydrated before

being

> consumed. The most frequent cause of vomiting is overloading the

> pouch. We encourage patients to continue to measure their meals

with

> their one ounce cups for weeks, even months, following the surgery

if

> they are experiencing difficulty with vomiting. We emphasize

> repeatedly that they should eat only until " comfortably satisfied "

as

> the word " full " has different meanings to different persons.

>

> SIX WEEKS

>

> Solid food is begun with emphasis on the fine cutting of fibrous

food

> to the size of the fifth fingernail or smaller, thoroughly chewing,

> three or more foods at each meal to prevent wadding up of similar

> fibers, eating only until " comfortably satisfied, " and beginning,

> even at this early date, to teach the concept of no liquids with

> meals for fifteen minutes before meals and for one and a half hours

> after meals.

>

> REASSURANCE OF ADEQUATE NUTRITION

>

> Many patients need reassurance that they can achieve adequate

> nutrition in the postoperative period. Without this reassurance,

some

> patients will deliberately eat six to eight times a day because of

a

> fear of malnutrition (often initiated by well meaning family

members

> and friends). We like to point out that in this short period of

time

> during the pouch growth, there are only two major nutritional

needs:

> protein on the one hand and vitamins and minerals on the other. The

> latter can easily be achieved by the patients routine twice a day

use

> of the vitamin supplements. Therefore, their only responsibility

and

> focus is to eat low-fat, animal-source protein at each meal, three

to

> four times a day. If they do this or simply come close to doing

this,

> they will end their first year post-op with a lower than pre-op

lean

> body mass but one that is appropriate to their body weight at that

> time.

> (reference 4)

>

> MEAL SKIPPING

>

> On the other hand, some patients are likely to skip meals when they

> have no appetite, similar to their behavior previously when their

> appetite has been diminished by over tiredness or illness. We

> emphasize the need for three to four meals a day, including

> breakfast, primarily to meet their needs for protein. We emphasize

> that one-half or more of each meal should be composed of this low-

> fat, animal-source protein (two-thirds of their meal in the distal

> gastric bypass procedures) in the first months until their pouch

> volume is large enough so that they can eat at least two ounces of

> protein at each meal.

>

> ARTIFICIAL SWEETENERS:

>

> We warn our patients to be aware of using artificial sweeteners if

> they are experiencing hunger in this early p.o. period. We have

> evaluated a few patients who experienced very strong hunger

cravings

> in the first weeks or months post-op whose hunger abruptly ceased

> with stopping artificial sweeteners.

>

> AVOIDING ABSOLUTES

>

> There are so many rules that we teach concerning the use of

> the " pouch/tool " that we believe that it is important to emphasize

to

> the patient that it is not necessary to follow every rule all of

the

> time. We actually suggest that it is perfectly all right to break

the

> rules once in a while- the important thing is to be aware that one

is

> breaking the rule and having a reason for it even if that reason is

> simply alleviating frustration. We point out that the only penalty

> for eating a liquidy meal when appetite has returned is the earlier

> return of hunger in the next four to five hour period. There is no

> lasting effect beyond that next meal. We also point out that

deciding

> to take advantage of a social opportunity to eat a high calorie,

> empty calorie meal is the ingestion of a relatively insignificant

600

> to 1,000 calories instead of the 3,000 to 5,000 calories that could

> be consumed in such a meal with a normal stomach volume.

>

> THREE MONTHS

>

> At three months we step up the teaching of the nutritional or

protein-

> containing value of foods related to the " cost " of that protein

food

> in terms of calories consumed, i.e. a gram of cottage cheese

> protein " costs " only five calories, but a gram of cheddar cheese

> protein costs sixteen calories, and peanut butter twenty-four

> calories. Water loading techniques (see below) are introduced at

> three months postoperatively as some patients will begin to see a

> return of appetite before their six month office visit. Overall

fluid

> management is discussed, emphasizing how the Gastric Emptying Test

> illustrates the principles of fluid management (see below).

>

> THREE PRINCIPLES FOR GAINING AND MAINTAINING SATIETY

>

> 1. The pouch needs to be truly filled with adequate wall distention

> with each meal (i.e. no snacking).

>

> 2. Keep the pouch filled over time and slow down the emptying time

> (by eating solid foods and avoiding liquids for fifteen minutes

> before and one and one half to two hours after eating. We

understand

> this to be the most important lifestyle change after the gastric

> bypass procedure. Figure 3 shows the results of a standard gastric

> emptying test using radioactive sulfur with a scrambled egg, bread,

> and milk. With the milk, 90% of the meal volume has exited the

> stomach within forty-five minutes. However, without the milk, only

> 45% of the meal has exited the stomach by ninety minutes.

>

> 3. Finally, adequate protein with each meal. We emphasize three

meals

> a day including breakfast (defined as the first meal of the day

which

> is eaten within one to two hours after arising). We define

> the " enemy " as high calorie liquids. We point out that snacking and

> high calorie liquids cheat the patient because the calories are

taken

> in without offering significant satiety.

>

> FLUID LOADING

>

> Fluid loading is the rapid drinking of a non-calorie or low-calorie

> liquid on an empty stomach in order to achieve a maximal intake of

> water at that time and/or achieve immediate satiety which lasts for

> fifteen to twenty-five minutes. About 80% of the estimated maximum

> capacity at any given time should be drunk rapidly over fifteen to

> thirty seconds and then topped off with swallows until full satiety

> is reached. Patients rather rapidly determine what their capacity

is,

> and it usually is between eight to twelve ounces when the Cottage

> Cheese Test volume is four to six ounces. The fluids should not be

so

> cold as to be uncomfortable, but it is not necessary to be warm.

The

> mechanism of action is presumed to be the distention of the Roux

limb

> with subsequent contraction, stopping the progression of fluid

> downwards and backing up the volume and pressure into the small

pouch

> and, perhaps, even into the distal esophagus. Fluid loading works

> with the banded gastroplasty as well but not quite as effectively.

> The mechanism here is probably primary distention of the pouch with

a

> fluid as it is passing through. The volume required is usually

> somewhat greater, but it still is far less than two to four glasses

> of water required in a normal sized stomach. Clearly, this small

> proximal pouch is quite sensitive to distention, and the satiety

> gained from that distention lasts far longer than the distention

> itself. We teach patients to fluid load before each meal in order

to

> help prevent post meal thirst, but also to fluid load whenever they

> feel the sensation of hunger and are tempted to snack.

>

> POST PRANDIAL THIRST:

>

> It is important that the patient be fully hydrated before coming to

> the next meal because the solute load of the meal will create

> postprandial thirst. It seems intuitive that persons cannot

tolerate

> thirst any more than they can tolerate hunger over the long run as

> both hunger and thirst are primary noxious stimuli. Initially, when

> the functional pouch volume is quite small, the solute load is

> correspondingly small, and the patient may not see the point of

> adequate rehydration and pre-meal fluid loading. However, as the

> pouch volume increases and the solute load increases, it becomes a

> significant issue in maintaining that important proscription of

> avoiding liquids during and for an hour and a half after the meal.

>

> URGENCY

>

> In these first months we like to emphasize to patients that their

> golden opportunity for maximizing their weight loss is in the first

> six months after surgery. We illustrate this with the weight loss

> curve, with its rapid downward sweep, with two-thirds of their

weight

> being lost in the first six months postoperatively. The Cottage

> Cheese Test shows that two-thirds of the pouch growth occurs in the

> first six months. Therefore, we teach our patients that every day

> during this early period the exercise and activity that they do

will

> be more effective in burning calories in excess of their calorie

> intake than the same amount of activity/exercise the following

> day. . . and a little less effective than the previous day based on

> progressive pouch growth. I.e. every single day the patient should

> take advantage of their present opportunity and get as much

activity

> as they can, knowing that never again will that same amount of

> activity result in as much weight loss. We try to give them a sense

> of urgency about getting the most out of every day.

>

> SIX MONTHS

>

> At this point, or soon after, our patients are beginning to get

> hungry before their next meal, and we accelerate the teaching of

> satiety mechanisms and the prevention of post meal thirst. As the

> meal solute volume increases, they need to push enough fluids in

the

> two to three hours before the meal to gain good hydration with

final

> water loading fifteen minutes before the next meal.

>

> INTAKE INFORMATION SHEET AS A TEACHING TOOL

>

> At each visit from three months to two years, the patient is asked

to

> complete a form before they come into the office. The form queries

> them about their performance on the principles of pouch use (as

well

> as vitamin usage, exercise, pathological symptoms, etc.). This form

> is designed so that it is also a teaching tool- each question

reminds

> the patient about the principles of the use of their pouch/tool.

> Many, if not most, patients do very well, and their weight loss is

> progressive and satisfying. Some struggle to make the lifestyle

> changes necessary, but with these periods of intermittent

monitoring,

> encouragement, and teaching they progressively learn and most do

> well. A few patients never seem to understand or to remember these

> simple principles even though they might be quite intelligent,

> capable persons in other facets of their lives. . .

>

> HONEYMOON SYNDROME

>

> The profound satiety that patients experience in the first six

> months, along with the rapid weight loss due to intake restriction,

> can lead certain patients to believing that these circumstances

will

> never change in spite of the clear teaching of our patient

> information booklet and clinic visit handouts. For these patients,

we

> will then see a slackening off on their food selection and liquid

> calorie control and see them indulge in more recreational eating.

> They will cut back on their exercise as they seem to be losing a

> great deal of weight without exercising. Their weight loss will

> subsequently slow. We have dubbed this situation the " honeymoon

> syndrome " and tried to educate our patients, even in our

preoperative

> informational booklet, that they can expect this temptation to

occur

> and that they must not get " suckered " into a false sense of comfort

> that leads them to not make a sufficient effort in their own behalf

> and miss this golden opportunity for weight loss. We have found

that

> an effective tool for identifying and reality-orienting the patient

> is to graphically compare that patient's weight with the mean

weight

> loss of the group as a whole. Whatever the patients beginning

weight

> is, we would expect them to parallel the weight loss curve. If

their

> weight deviates from the expected, we should be able to find a

reason

> for it and to correct it if the patient is willing to learn and

make

> this needed lifestyle change.

>

> EXERCISE

>

> Although this chapter is about understanding the function of the

> small proximal gastric pouch and how it relates to patient

> management, a word must be mentioned about exercise. We believe

that

> the scientific data overwhelmingly demonstrates that 1) exercise is

a

> critical part of a healthy lifestyle for patient and doctor alike,

> and 2) that exercise is necessary to maintain weight loss in the

> obese patient. Therefore we believe it must be a critical part of

our

> postoperative patient teaching and encouragement. Exact details are

> beyond the scope of this presentation, but we do emphasize to the

> patients that the feelings of vigor and energy are in no way

> guaranteed by a slender figure. Observations of people on any city

> street confirm this. . . We emphasize that the release of

endorphins

> with aerobic exercise improves emotional stability and mental

clarity

> and helps any person to cope with the deprivations and annoyances

of

> everyday life. Endorphins, adrenalin, norepinephrine, etc., also

act

> in an antidepressive manner. But most importantly, especially in

the

> first six month period when the gastric pouch is so small, regular

> aerobic exercise maintains, or even improves basal metabolic rate

> that is observed to drop during rapid weight loss.

>

> THE IDEAL MEAL FOR WEIGHT LOSS

>

> The ideal meal for weight loss is one-half of the meal volume up to

a

> total volume of two to three ounces of animal-source, low-fat

protein

> plus filling the rest of the pouch volume with low starch

vegetables

> and solid type fruits such as apples and pears. Cut finely and

chewed

> well, these foods represent coarse, solid food choices that are

> likely to stay in the pouch longer and offer good nutritional

value.

>

> VOLUME VERSUS CALORIES

>

> A person with a normal stomach tends to judge how much he/she needs

> to eat at a given meal by approximately how many calories are in

that

> meal (although not necessarily thinking of calories as such). In

> other words, we know that we are going to be unpleasantly hungry

> before dinner if our noon meal consists of a green salad and a

couple

> of ounces of cottage cheese. Calories are what keep us from getting

> hungry between meals. On the other hand, the post-op gastric bypass

> patient needs to learn to think about the volume and consistency of

> food choices rather than their caloric content when judging how to

> prevent getting hungry before the next meal. I recall a lecture I

> once attended in which the lecturer pointed out that one or two

> sticks of butter could meet our entire calorie needs for the day

and

> could be easily consumed by even the small post-op gastric bypass

> pouch. However, that same number of calories in the form of non-

> starchy raw vegetables could not be consumed by a person with a

> normal stomach in only three meals a day. There is an enormous

> variation between calories and volume, and a patient needs to learn

> how to " think volume " when making food choices to gain and maintain

> satiety in a mature small gastric pouch.

>

> ISSUES FOR LONG TERM WEIGHT MAINTENANCE

>

> The previous comments are primarily designed to deal with patient

> issues in the first year following a gastric bypass procedure.

These

> issues should seamlessly slide into long term weight maintenance

and,

> indeed they do so in most persons.

>

> COUNTER-INTUITIVENESS OF FLUID MANAGEMENT:

>

> It is clear that avoiding liquids with meals and pushing fluids

> between meals is counter intuitive. The large capacitance of a

normal

> stomach is a great convenience factor for that person and, truly,

all

> animal life. There is a resistance to learning this technique, and

> clearly it is counter intuitive to the experience of the

individual.

> However, if it is important that solid food be taken rather than

> liquidy food to maintain satiety, then it is clearly important to

> avoid liquids with meals or soon after meals as the liquid will

> simply make the food more soup-like and soft and allow more rapid

> emptying of the pouch and, therefore, shorten the period of

satiety.

>

> SUPPORT GROUPS

>

> We have found that support groups are very effective in reinforcing

> the principles of the pouch/tool use. Many, if not most, patients

> will explore these principles on their own by using them and then

for

> a time not using them. Some patients on their own become convinced

of

> the value of these principles through this natural experimentation.

> However, others may lose their way. The support group offers an

> excellent feedback mechanism for individuals who need reinforcement

> of the principles of the pouch use. Sometimes, the feedback of

their

> peers is more effective than that of the parental figures in the

> surgeon's office.

>

> TEETER-TOTTER EFFECT

>

> One " visual " that we use when discussing weight maintenance is that

> of a teeter-totter. On one end of the teeter-totter is the

> exercise/physical activities, and on the other end is the meal

choice

> discipline and fluid restrictions. When one has a large amount of

> exercise and activities, the teeter-totter swings down on that end,

> and the amount of effort that need be placed on diet discipline

> lightens up. When one is light on the activity/exercise, one has to

> be much heavier on the diet discipline side. If one is light on

both

> exercise and diet discipline, the whole teeter-totter moves upward

as

> weight is gained. On the other hand, if one is " heavy " on both

> exercise and diet discipline, the teeter-totter bar goes down, and

> weight is lost.

>

> TOO MUCH WEIGHT LOSS

>

> There are a group of patients in our practice, approaching 15%, who

> lose too much weight in the one to two year period postoperatively.

> Inevitably, these individuals were only 100 to 150 pounds

overweight

> to start with and are good exercisers. We encouraged them to taper

> off their efforts with diet discipline (maintaining their exercise

> routine and thus their vigor) by adding some fat back to their

meals

> and eating a fourth or fifth meal a day with less discipline on the

> fluid management. Basically, it is an exercise on " how to beat the

> pouch. " The pouch can be beaten by one, liquid high calorie meals;

> two, frequent meals or grazing; three, eating a meal over thirty to

> forty-five minutes; four, adding liquid to meals to enhance gastric

> emptying; five, liquids are taken shortly after eating which

> increases gastric emptying and decreases the satiety period. Some

> patients take our advice and taper off their weight loss before

they

> go underweight. However, a small but significant group of patients

> actually go underweight because all of our patients have

experienced

> the rapid and frightening return of severe hunger cravings when

going

> from one of their many diets to trying to eat normally once again.

> Very similar to a bear coming out of hibernation, their suppressed

> appetite center seems to burst out with vigor in order to save the

> life of this person who the appetite center sees as a normal weight

> person having suffered in a famine. Many patients at this point

have

> not yet fully accepted that they have had a true anatomic and

> physiologic change from their operation and that, using the

> principles of the pouch/tool, a return of this overwhelming

appetite

> will not occur. For these persons, it is not until their lean body

> mass is effected and they lose their delightful sense of vigor that

> they will begin to " break the rules " and gain some needed weight

> back. This is probably the primary reason why, in most bariatric

> surgical practices, the weight loss curve bottoms out at eighteen

to

> twenty-four months with a rise at two to three years. This rise has

> been erroneously interpreted as most patients regaining 10% to 15%

of

> weight from the nadir of their weight loss.

>

> BARIATRIC MEDICINE

>

> A much more common problem is that of patients who have not lost as

> much weight as they would like and are plateauing at a level above

> their goal weight. Bariatric medicine techniques can be useful in

> helping our postoperative patients who find themselves stuck on a

> plateau one or more years postoperatively. However, there can be a

> problem with standard weight control and dietary teaching of

> Bariatric medicine. The frequently used recommendations of frequent

> small feedings or liquid calorie fasts such as a protein sparing

> modified fast, neutralizes the satiety function of the pouch/tool,

> and tends to negate the teachings of the principles of the pouch

use,

> and therefore is probably not an optimum way of managing the

patient.

>

> SUMMARY

>

> The principles of the postoperative bariatric surgical follow up

> management are as follows:

> 1. Understanding the fundamentals of the anatomy and physiology of

> the pouch/tool.

> 2. Evaluating the patient's appropriate or inappropriate use of the

> tool- What is lacking? What is being done well?

> 3. Instruct patient with words, drawings, analogies, encouragement,

> and passion, on not only what to do but why it needs to be done.

>

> The goal is to make the patient become fully knowledgeable about

how

> to control their own weight over the long term through the

> appropriate use of their pouch/tool, combined with a reasonable

> amount of exercise.

>

> EVALUATION FOR WEIGHT LOSS FAILURE

>

> Evaluating a patient who is progressively regaining weight can be

> relatively simple- or extremely difficult. The first principle is

to

> determine that the gastric pouch is anatomically intact. If it is

not

> intact, it should be made intact by a revision procedure. Only when

> the surgeon can be reassured that the pouch is intact does the

> complex part begin- evaluating how and why the patient is not using

> the pouch/tool properly, and/or getting a reasonable amount of

> exercise.

>

> We need to know three things about the small gastric pouch. First,

is

> the staple line intact; second, is the outlet intact; and third, is

> the pouch reasonably small in size.

>

> The upper GI series with thick barium is the basic tool for

> evaluating intactness of the staple line and the outlet. If the

pouch

> has been stapled in continuity with the rest of the stomach, we

must

> confirm that the staple line remains intact. An eventration of the

> staple line will create two gastric outlets leading to rapid pouch

> emptying, early loss of satiety, and thus early return of hunger.

An

> important clue from the patient's history is the presence of a

> marginal ulcer after a gastric bypass. Marginal ulcers do occur,

> occasionally, with an intact staple line. However, they are more

> common with a small hole in the staple line that results in food

> stimulation of the antrum. If there is a staple line eventration,

the

> marginal ulcer is unlikely to be able to be controlled without

> reoperation and closure of that eventration, preferably with

complete

> division of the small pouch from the distal stomach.

>

> The upper GI series with thick barium in the hands of an

experienced

> radiographer can usually give the bariatric surgeon a reliable view

> of the diameter of the gastric outlet. A diameter of over 18-20

> millimeters is usually associated with weight regain, and we term

> this " outlet failure. " Outlet failure, like a staple line

> eventration, causes rapid emptying of the pouch, early loss of

> satiety, and early return of hunger.

>

> On the other hand, weight regain can occur as a result of an outlet

> diameter under 7-8 millimeters which can lead to persistent

vomiting

> of solid foods and gradual persuasion of the patient towards the

Soft

> Calorie Syndrome with resultant rapid pouch emptying, early loss of

> satiety, early return of hunger, and weight regain.

>

> The upper GI series is less effective for evaluating pouch volume

> because of the fact that barium is very much of a liquid. To assess

> pouch volume, you must turn to the patient's history of the size of

> the meal that he/she can consume within a short five to fifteen

> minute time frame, and/or to the Cottage Cheese Test (see above).

>

> In the patient whose gastric pouch seems to be anatomically intact

> and yet he/she is still regaining weight, the evaluation becomes

more

> complex. The usual finding is that the patient is not following the

> principles of the use of their pouch/tool and/or is extremely

> inactive physically. There are four problems that occur with some

> frequency: the patient has never been taught/or does not understand

> how to use the tool; the patient is significantly depressed; or

loss

> of contact with a bariatric practice and other bariatric patients

and

> a gradual erosion of following the principles; or the patient is

> truly noncompliant and will not take responsibility for his/her own

> behavior.

>

> LACK OF TEACHING

>

> An excellent example of the lack of teaching/understanding of how

the

> pouch works is found in the history of GC. GC is a 62-year-old

woman

> who presented in consultation for a total regain of her weight and

> complaint of constant hunger, sixteen years following a gastric

> bypass procedure in Cambridge, Massachusetts. She stated that she

had

> not seen the surgeon beyond the six week follow up visit. She

> understood nothing about how to use her gastric pouch. She

initially

> lost fifty pounds and then another forty pounds further with the

help

> of a commercial weight management program. For the next ten years

she

> yo-yoed up and down with the usual peer group and doctor supported

> programs with a gradual increase in weight and the usual hunger and

> deprivation syndromes relating to these programs. She then

developed

> myasthenia gravis and her weight regain escalated to her

preoperative

> weight, resulting in the referral. At the time of the referral she

> was being treated effectively for myasthenia gravis and was

> reasonably active, being able to walk over a mile at a time. Her

> weight loss curve with its abrupt turn around and rapid weight loss

> (figure 4) could be consistent with a revision reoperation.

However,

> there was no revision done. After evaluation of her pouch/tool with

> an upper GI series and a Cottage Cheese Test/functional meal volume

> estimation, she was given the basic instructions of how to use her

> pouch/tool, the same given to all of our postoperative patients.

Her

> ensuing and continuing weight loss is impressive, but more

impressive

> to the patient is that she is not experiencing any distressing

hunger

> cravings, food fantasies, or food dreams as she had experienced

with

> all of her previous efforts, since the first months after her

gastric

> bypass procedure sixteen years ago.

>

> DEPRESSION

>

> Depression is a powerful inhibiter of success after bariatric

> surgical procedures. A small but significant number of our patients

> have been doing well following their gastric bypass procedure only

to

> drop out of sight for a time and then reappear with a significant

> weight regain. Upon evaluating these patients, it would appear that

> in many instances they seemingly deliberately reverse all of their

> learned principles of the use of their pouch/tool: grazing and

> snacking through much of the day, drinking high calorie liquids,

> drinking liquids with meals, and stopping their exercise, even when

> they are intellectually aware that exercise in itself releases

> numerous vasoactive substances which act like antidepressants. DB

is

> a 46-year-old woman who had an excellent initial weight loss

> following a gastric bypass procedure (figure 5). While still in the

> first year after her gastric bypass, her life, already made

difficult

> by divorce and economic circumstances, became severely disrupted

when

> her only daughter developed a drug problem, an abusive

relationship,

> and finally HIV, and was forced to give up her newborn child. Her

> weight regain was dramatic. However, even more dramatic was her

> weight loss once her depression eased, and she was able to look

after

> herself once again. She relates that she did nothing dramatic such

as

> fasting. She simply returned to using her pouch/tool in the manner

in

> which she had been taught and resumed a moderate exercise program.

> What can the bariatric surgeon do when patients are obviously

> depressed and regaining weight? Obviously, the most important thing

> is to steer them to professional counseling, if they are not

already

> in counseling. Then, the surgeon can be encouraging. We can

encourage

> them to continue to use the tool as best as they can; we can

> encourage them to return to exercise which will improve the spirits

> and reassure them that the improvement is " deserved, " " because you

> really are a good person, and you deserve to feel better. . . " Most

> of all, the surgeon can reassure them that the pouch/tool is not

> ruined by this overeating and gradual weight regain if it does not

> result in persistent vomiting of solids. When they are ready once

> again to use their pouch/tool, it will be there for them, and they

> will be able to once again lose weight without being hungry.

>

> EROSION OF THE USE OF THE PRINCIPLES:

>

> In a third subset of weight maintenance failure patients, a subtle

> weight creep can occur to patients who are otherwise compliant, non-

> depressed, and have intact pouches. The patient will see it

> as " struggling " with his/her weight, and by definition, he/she will

> not have seen you in follow up and will have usually lost contact

> with the support group or other bariatric surgical patients. There

> seems to be a progressive erosion of following the principles of

the

> pouch/tool use. This may be due to denial as seen in diabetic

> patients, or it may be due to the influence of their peer group and

> the fact that some of the principles of the use of the pouch/tool,

> especially fluid management, are counter- intuitive and counter to

> behavior of their peer group. The patient will often not come back

> for evaluation because " I know what I'm doing wrong! " (meaning that

> he/she is eating the wrong things and too often), and these

patients

> will internalize their " failure " with an increasing sense of guilt

> which itself acts as an inhibition to coming back to their

surgeon's

> office for help.

> From the beginning, in our preoperative teaching, we emphasize the

> possible need for a " refresher course " in the use of the principles

> of the pouch/tool at some time in the future. Some patients still

do

> not return. The trick is identifying these patients and somehow

> getting them back either into the office or into a support group.

> In these three examples- lack of teaching, depression, and gradual

> erosion of the use of their tool, weight once regained can be lost

> once again if the pouch is anatomically intact and the patient

> decides to use it, or learns how to use it or relearns how to use

it.

> In these three examples, we are working with compliant, reasonably

> responsible persons who, when they can, are willing to take

> responsibility for their own behavior.

>

> TRUE NON COMPLIANCE:

>

> The most difficult problem is determining, and being comfortable

with

> that determination, when a patient is being fundamentally

> noncompliant and obstructive. This type of individual may leave

your

> care and go to others complaining about a " personality conflict, "

or

> perhaps even that you have not given them the time and attention

that

> they need and deserve. Inexplicably, some will actually stay in

your

> care. In this instance, when the patient tends to return perhaps

even

> more frequently than usual, depression will be more likely the

> underlying mechanism rather than noncompliance. It can be difficult

> to be reasonably sure of what is going on in one or two visits. The

> truly noncompliant patient will very likely end up with multiple

> revisions and/or a reversal due to weight regain or complications.

> This kind of patient is often quite resistant to counseling, but I

> know of no other management option that offers much hope for

success.

> Luckily, this type of patient represents a very small minority of

our

> patients. Obviously, prevention in the form of patient selection is

> better than cure, but after twenty-three years of a bariatric

> surgical practice, I have yet to be able to effectively identify

> these persons preoperatively. I have, in fact, suspected

significant

> noncompliance in a number of my patients who have turned out to be

> quite compliant particularly after control of other problems, such

as

> sleep apnea, that effect understanding and complying with our

> instructions. With the current lack of an effective psychological

> screening tool to reliably identify these individuals, I tend to

lean

> towards giving each person a chance at a good and healthy life

> provided by bariatric surgery.

>

> BIBLIOGRAPHY

> 1) Mason, EE, Personal Communication, 1980

> 2) Barber, W, Diet al, Brain Stem Response To Phasic Gastric

> Distention. Am J. Physiol 1983; 245(2): G242-8

> 3) Flanagan, L. Measurement of Functional Pouch Volume Following

the

> Gastric Bypass Procedure. Ob Surg 1996; 6:38-43

> 4) Rosemurgy, A.

>

>

>

>

>

>

>

>

>

[Guest guest]

,

Thanks for sharing that article. No wonder I'm on a 2-month plateau,

I've been unintentionally " beating the pouch " , eg, eating 4/5 meals a

day, drinking during meals, and grazing during the day. I never

thought too much about the pouch as a " tool " , I've just been

eating/drinking what and when I want.

This article has been a lesson in using the pouch " tool " .

Bern

TX

MGB 7/24/00

248/167

[Guest guest]

This is very interesting and I believe it may be very true. I am going to

continue to study this! Personally, my weight loss has been very fast and I

do and have always believed it is due to my change in lifestyle and exercise

levels, but as I wrote earlier, I must monitor my exercise level in the heat

to ensure that my outtake is not greater than it should be.

Personally, I find most animal-based low-fat protein very unpalatable! The

only exception is fish. I was raised and born in West Texas where the

closest lake was approximate 5 hour drive; therefore, fish was not a food

that I at often. I am learning how to cook fish in different ways plus the

different types of fish. If anyone has good fish receipts, I would love to

try them!

Debra in Tulsa

03/14/01- 320/200