Perhaps it’s the time of year (after the excesses of the holiday season and Easter); the start of the summer; launch by many more companies of ‘magical’ pouch test ‘cures’; and all the rest, but my mailbag and inbox has been inundated with queries on ‘stretching the pouch’ and how to overcome ‘WLS regain’ just recently.
I felt it was therefore high time to re-visit this topic that we have covered before as a post (see here). It still makes good reading and there’s some useful tips there to prevent over-eating. And there’s a previous guest post review about pouch re-sets too worth the read (see here).
There’s always so much to check up on, and keep up with, in this relatively new area of bariatric surgery and I wondered what the pros now thought; had there been new scientific evidence to put a new slant on what has been recommended in the past; and what was the feeling, anecdote wise, from patients and bariatric teams worldwide on the subject.
I have therefore embarked on a big research trawl of everything I can find – and there has been lots – and then an exercise to try and condense the outcome of what I have found. In places it has been easy – nothing new to report – in others it has been a labour of love to seek out those who are willing to speak up about the good, the bad and the ugly relating to this. Not least is that there are affiliations here and there where money and business are concerned. Make no mistake there are still people out there who prey on the dieter and a WLS one is no exception.
So here it is – my take on this (which may not be yours or others) and I think you know by now that I don’t sugar-coat the truth. My findings are based on what I have found scientifically to support or deny ‘pouch stretching’; what you can do if you think you have ‘stretched your pouch’; what ‘pouch re-sets’ do and don’t do; and my feelings around the subject.
It’s not a short feature (as you may have guessed) but I am hoping with a long weekend coming up for many of you that there may be some time in a quiet moment to read this important question relating to WLS – or ‘park it’ and read later.
I don’t doubt there will be quite a few responses to this, and I welcome all, but can I make a plea that you read what is said before commenting in a knee-jerk way. Only by reading the entire feature can you get a grasp on what is recommended and why. It would be unnatural for us all to agree but let’s look at the evidence first …
SOME BACKGROUND ON THE REAL WORRIES AFTER WLS
Weight regain is one of the major worries and concerns after WLS. Many experience it to some degree or another and some query whether in doing so they have stretched their pouch. Others think that a stretched pouch means their surgery is no longer effective and that they have ‘ruined’ their surgery and chance of long-lasting success.
Some regain is expected by just about all bariatric teams after surgery and they predict this will happen several months down the line as the body adjusts to it’s new size and the patient also comes to terms with and moderates their new eating pattern (and seeks to control it). Many patients I come across say they reached an all-time low or goal weight and then settle at about 5 -7 lbs (2-3 kg) above that. The sign that all is not as it should be comes when that boundary or limit is reached and then exceeded. Most simply cut back (either on portion size or on foods they feel are responsible) and loss is then experienced again and the equilibrium or maintenance weight is restored.
Weight fluctuation is to be expected but if the scales are travelling continually north then it is often time to check a few things out. We have suggested in many features that portion size is a good one to scrutinise; food choice another (write down what you’re eating and analyse it); check your hydration and sleep levels (both important with weight maintenance); and then look at what other contributory factors could be at play – exercise, stress, medications etc.
Many, in looking at these factors, may also be a little panic stricken and think they are right back at pre-op status and query if they have now stretched their pouch and ruined everything the surgery afforded and ‘promised’ in being a solution for their obesity. I confess on occasions my own mind has wandered into this territory. But with my journalist’s/writer’s/food expert’s hat on I do tend to research and check out these notions before believing the worst.
HOW DOES THE STOMACH WORK?
My first enquiry is often a very logical one – is it physically possible, is it medically likely, what are the chances of this ‘pouch stretching’ scenario? This is what my research told me …
Your stomach is a muscular organ about the size of your fist. Regardless of the new size of this pouch (and it does vary from individual to individual and also by procedure) it is very hard (and much more difficult than you think) to stretch it out. It’s a very resilient organ that is layered in muscle. It’s not thin and fragile, like a balloon, nor like an elastic band that stretches and then doesn’t quite go back to its original size. So overeating a few meals will not undo your weight-loss surgery in the way you maybe think it will.
To begin with your stomach/pouch will be sensitive and not able to deal with very much food because it is healing – and it’s very necessary not to upset it with too much food, nor food that is too firm or textured during this slow healing process (at least 8 weeks in most cases, and often longer). We get very used to our pouch being ‘small’ or restrictive during this healing process and comply with all the advice we are given about progressing through the stages of eating after surgery. Most of us pay close attention and treat this ‘new baby’ with all the care and attention it requires. Occasionally we may test it by moving on a stage too soon but, either through discomfort, complications, sensitivity or inflammation, we are brought to heel and realise this takes time. Some who push it a bit too far may well need to consult with their bariatric team if they suffer severe symptoms or they don’t improve, but it’s rare.
But it’s then, after the this healing phase, that liberties might be taken and you might well find that you’re eating more than you feel comfortable with; feeling more and more hungry, find you can drink more than you could sip earlier – and, understandably wonder if you have inadvertently, or even knowingly, pushed things too far, and stretched your pouch.
Is this possible – to stretch your pouch?
The good news is that it is incredibly difficult to stretch the stomach/pouch to a degree that you have so-called ‘ruined your surgery’. This wonderfully resilient organ is more likely to contract all it’s layers of muscle and object – which (and there’s no nice way of putting this) make you feel very unwell or vomit to eject the excess. This can happen with ill-judged food types, lack of chewing, eating too fast, or eating beyond satiety.
Where the bad news comes in is where you attempt to eat around the restriction that the stomach/pouch brings.
It’s not that the restriction has gone, but you’re eating around it.
If you’re eating more, seeing regain, or experiencing issues with eating (like sensitivity, dumping etc) then it’s more likely to be an issue of what you are eating (or have eaten) or how you ate it. You are more likely to assume that you have stretched your pouch and this lies at the heart of the problems you experiencing, but if you ask yourself some questions about your meal pattern, the texture of the food you eat, the speed of your eating and whether you are drinking and eating at the same time there may be some answers to hand.
MEAL PATTERN & GRAZING: This often means you are not sticking to set meal times that last roughly 20 minutes long but instead last a period of time when you eat and then go back for more until your portion is gone. Or maybe it can mean you graze on soft textured ‘slider’ foods that go down easier so you don’t feel proper restriction.
THE RIGHT TEXTURE OF FOOD TO EAT: Most WLS patients will tell you that they can eat more spoonfuls or weight of soft textured food (like say Shepherd’s Pie) than firm protein (like roast chicken). These softer foods mean that you can also fit more in your pouch – which means a bigger portion size and often also comes hand in glove with getting hungrier again soon, since restriction (that comes from firmer textures) is lost or impaired.
SPEED OF EATING: Another culprit if you are eating too fast or too big a bite of food. This may mean you suffer from ‘premature fullness’ where you think you are full and stop eating but then find yourself hungry well before the next meal time.
DRINKING & EATING AT THE SAME TIME: Drinking fluids along with your meal means that food will move through your stomach much faster than ideal – so again you can fit in more than optimal and you don’t experience restriction from that food.
Many of these can be resolved by following the 20:20:20 rule (see here)
These are more likely reasons, than a medical reason (or pouch stretching), to explain any stall, plateau, regain or poor eating issues relating to surgery.
For most getting back to basics is the right and most sensible way to restoring your pouch and it’s restriction. We have a back to basics checklist (see here) that covers just about everything. It should really be your first port of call.
It may sound harsh, but don’t blame your surgery or your pouch for not working, it’s most likely the habits you’re employing or have gone back to.
The good news is that you don’t need to look at additional surgery to fix this restriction in the majority of cases. You just need to sit down, reflect on what you are eating, when, how and what size portion, and then identify why your restriction has decreased, and then (by going back to basics and pressing that re-set button) restore restriction and make your pouch effective again. In other words give it another chance! This isn’t a one-trick pony … RESTRICTION CAN BE RESTORED.
POUCH TESTS & RE-SETS
HOWEVER, many patients do look for other ways to restore this restriction and resort to pouch tests to re-set their stomach to its ‘original size’ after surgery, to gain control over their unhealthy creeping eating habits, and to kick start weight-loss or reverse weight gain. I fully understand the need to find a ‘fix’ – a quick one, and one that is discussed as ‘safe’ and ‘works’ in forums, on websites and in anecdotal literature or conversations.
But the simple fact remains that pouch re-sets simply play into bariatric patients’ fear that they are putting on weight because they have ‘stretched’ their stomach/pouch. Which from previous paragraphs you can see is highly unlikely. It does not take into consideration that the stomach has a natural capacity to stretch because it is a muscle. When it has healed after surgery, it continues to work like a normal un-operated organ, and your capacity to eat more increases. The size of your pouch has nothing at all to do with whether or not you regain weight after WLS (regardless of type). The majority of weight gain is caused by what you are eating after surgery, the timing of your meals and snacks, and how you are eating.
All the surgeons and professionals I have spoken to about this are clear – the pouch re-set scenario is a myth:
- It can’t shrink your stomach back to it’s early post-surgery size
- It does not reduce hunger and increase the feeling of fullness (satiety)
- It’s doesn’t ‘re-set’ your body
- It doesn’t drastically reduce you cravings for carbs and sweet/salty foods
At best, and this should not be overlooked, it simply works by restricting your caloric intake, which then causes you to lose weight. It may also remind you about your food choices again, about chewing, about portion control, drinking with meals – and indeed anything else that is covered in a Back to Basics regime.
What has indeed worried me is the lack of scientific evidence in medical literature to support such pouch re-sets. Be they 2-day, 5-day, 2-week or longer regimes – there is nothing to support them as being effective. And there are so many now – most (if not all) involve you with joining a community, a special food purchase opportunity or ‘buy the information’ transaction.
As an almost final word I go back to the original quote by a bariatric surgeon about this lack of scientific data or research that I relayed in our previous feature on pouch resets, and NOTHING HAS CHANGED! Nothing save the huge increase of special offers for these re-set tests and regimes.
“The major reason for weight regain is the recurrence of unhealthy eating habits and/or lack of exercise. Maintaining weight loss requires a lifelong commitment to keeping up good habits and having support from family, friends, and your health care team.
Searching through the medical literature, I could not find any evidence or scientific papers studying and discussing the 5 day pouch test. When something is not discussed in the whole of medical literature, even as a simple case report, it leads me to believe that there is no scientific basis for this re-set diet. And simply thinking about how the gastric pouch and anastomosis works, it does not make logical sense to me how a 5 day regimen of liquid and puree diet could possibly shrink the gastric pouch. The original feeling of tightness immediately after surgery is probably because of inflammation, since the stomach was cut and stapled, and also there was inflammation from the creation of the anastomosis (suturing). This inflammation resolves after days/weeks during which time the stomach is healing, and hence the original tightness feeling resolves with it”.
Dr. Simon Chow, Bariatric Surgeon, MD MSc FRCSC FACS