The nerves tell the brain the pouch is distended and that cuts off hunger with a feeling of fullness.

What is the fate of the pouch? Does it enlarge? If it does, is it because the operation was bad, or the patient is overstuffing themselves, or does the pouch actually re-grow in a healing attempt to get back to normal?

For ten years, I had patients eat until full with cottage cheese every three months, and report the amount of cottage cheese they were able to eat before feeling full. This gave me an idea of the size of their pouch at three month intervals. I found there was a regular growth in the amount of intake of every single pouch. The average date the pouch stopped growing was two years. After the second year, all pouches stopped growing. Most pouches ended at 6 oz., with some as large at 9-10 ozs. 

We then compared the weight loss of people with the known pouch size of each person, to see if the pouch size made a difference. In comparing the large pouches to the small pouches, THERE WAS NO DIFFERENCE IN PERCENTAGE OF WEIGHT LOSS AMONG THE PATIENTS. This important fact essentially shows that it is NOT the size of the pouch but how it is used that makes weight loss maintenance possible.  

OBSERVATIONAL BASED MEDICINE: 
The information here is taken from surgeon’s “observations” as opposed to "blind" or “double blind” studies, but it is based on 33 years of physician observation.

Due to lack of insurance coverage for WLS, what originally seemed like a serious lack of patients to observe, turned into an advantage as I was able to follow my patients closely. The following are what I found to effect how the pouch works:

1. Getting a sense of fullness is the basis of successful WLS.
2. Success requires that a small pouch is created with a small outlet. 
3. Regular meals larger than 1 ½ cups will result in eventual weight gain.  
4. Using the thick, hard to stretch part of the stomach in making the pouch is important.
5. By lightly stretching the pouch with each meal, the pouch send signals to the brain that you need no more food.
6. Maintaining that feeling of fullness requires keeping the pouch stretched for awhile.
7. Almost all patients always feel full 24/7 for the first months, then that feeling disappears.
8. Incredible hunger will develop if there is no food or drink for eight hours. 
9. After 1 year, heavier food makes the feeling of fullness last longer.
10. By drinking water as much as possible as fast as possible (“water loading”), the patient will get a feeling of fullness that lasts 15-25 minutes.
11. By eating “soft foods” patients will get hungry too soon and be hungry before their next meal, which can cause snacking, thus poor weight loss or weight gain.
12. The patients that follow “the Rules of the Pouch” lose their extra weight and keep it off.
13. The patients that lose too much weight can maintain their weight by doing the reverse of the “Rules of the Pouch.” 

HOW DO WE INTERPRET THESE OBSERVATIONS? 
POUCH SIZE:  By following the “Rules of the Pouch”, it doesn’t matter what size the pouch ends up. The feeling of fullness with 1 ½ cups of food can be achieved.
OUTLET SIZE:  Regardless of the outlet size, liquidy foods empty faster than solid foods. High calorie liquids will create weight gain. 

EARLY PROFOUND SATIETY: 
Before six months, patients must sip water constantly to get in enough water each day, which causes them to always feel full.

After six months, about 2/3 of the pouch has grown larger due to the natural healing process. At this time, the patient can drink 1 cup of water at a time. 

OPTIMUM MATURE POUCH: 
The pouch works best when the outlet is not too small or too large and the pouch itself holds about 1 ½ cups at a time.

IDEAL MEAL PROCESS (Rules of the Pouch): 
1. The patient must time meals five hours apart or the patient will get too hungry in between.
2. The patient needs to eat finely cut meat and raw or slightly cooked veggies with each meal.
3. The patient must eat the entire meal in 5-15 minutes. A 30-45 minute meal will cause failure.
4. No liquids for 1 ½ hours to 2 hours after each meal.
5. After 1 ½ to 2 hours, begin sipping water and over the next three hours slowly increase water intake.
6. 3 hours after last meal, begin drinking LOTS of water/fluids.
7. 15 minutes before the next meal, drink as much as possible as fast as possible. This is called “water loading.” IF YOU HAVEN’T BEEN DRINKING OVER THE LAST FEW HOURS, THIS ‘WATER LOADING’ WILL NOT WORK.
8. You can water load at any time 2-3 hours before your next meal if you get hungry, which will cause a strong feeling of fullness. 

THE MANAGEMENT OF PATIENT TEACHING AND TRAINING: You must provide information to the patient pre-operatively regarding the fact that the pouch is only a tool: a tool is something that is used to perform a task but is useless if left on a shelf unused. Practice working with a tool makes the tool more effective. 

NECESSITY FOR LONG TERM FOLLOW-UP: 
Trying to practice the “Rules of the Pouch” before six to 12 months is a waste. Learning how to delay hunger if the patient is never hungry just doesn’t work. The real work of learning the “Rules of the Pouch” begins after healing has caused hunger to return. 

PREVENTION OF VOMITING: 
Vomiting should be prevented as much as possible. Right after surgery, the patient should sip out of 1 oz cups and only 1/3 of that cup at a time until the patient learns the size of his/her pouch to avoid being sick.

It is extremely difficult to learn to deal with a small pouch. For the first 6 months, the patient’s mouth will literally be bigger than his/her stomach, which does not exist in any living animal on earth.

In the first six weeks the patient should slowly transfer from a liquid diet to a blenderized or soft food diet only, to reduce the chance of vomiting.

Vomiting will occur only after eating of solid foods begins. Rice, pasta, granola, etc. will swell in time and overload the pouch, which will cause vomiting. If the patient is having trouble with vomiting, he/she needs to get 1 oz cups and literally eat 1 oz of food at a time and wait a few minutes before eating another 1 oz of food. Stop when “comfortably satisfied,” until the patient learns the size of his/her pouch. 

SIX WEEKS 
After six weeks, the patient can move from soft foods to heavy solids. At this time, they should use three or more different types of foods at each sitting. Each bite should be no larger than the size of a pinkie fingernail bed. The patient should choose a different food with each bite to prevent the same solids from lumping together. No liquids 15 minutes before or 1 ½ hours after meals.  

REASSURANCE OF ADEQUATE NUTRITION 
By taking vitamins everyday, the patient has no reason to worry about getting enough nutrition. Focus should be on proteins and vegetables at each meal. 

MEAL SKIPPING 
Regardless of lack of hunger, patient should eat three meals a day. In the beginning, one half or more of each meal should be protein, until the patient can eat at least two oz of protein at each meal. 

ARTIFICIAL SWEETENERS 
In our study, we noticed some patients had intense hunger cravings which stopped when they eliminated artificial sweeteners from their diets. 

AVOIDING ABSOLUTES 
Rules are made to be broken. No biggie if the patient drinks with one meal – as long as the patient knows he/she is breaking a rule and will get hungry early. Also if the patient pigs out at a party – that’s OK because before surgery, the patient would have pigged on 3000 to 5000 calories and with the pouch, the patient can only pig on 600-1000 calories max. The patient needs to just get back to the rules and not beat him/herself up. 

THREE MONTHS 
At three months, the patient needs to become aware of the calories per gram of different foods to be aware of “the cost” of each gram. (cheddar cheese is 16 cal/gram; peanut butter is 24 cals/gram). As soon as hunger returns between three to six months, begin water loading procedures. 

THREE PRINCIPLES FOR GAINING & MAINTAINING SAFELY
1. Fill pouch full quickly at each meal. 
2. Stay full by slowing the emptying of the pouch. (Eat solids. No liquids 15 minutes before and none until 1 ½ hours after the meal). A scientific test showed that a meal of egg/toast/milk had almost all emptied out of the pouch after 45 minutes. Without milk, just egg and toast, more than ½ of the meal still remained in the pouch after 1 ½ hours. 
3. Protein, protein, protein. Three meals a day. No high calorie liquids. 

FLUID LOADING 
Fluid loading is drinking water/liquids as quickly as possible to fill the pouch which provides the feeling of fullness for about 15 to 25 minutes. The patient needs to gulp about 80% of his/her maximum amount of liquid in 15 to 30 SECONDS. Then just take swallows until fullness is reached. The patient will quickly learn his/her maximum tolerance, which is usually between 8-12 oz.

Fluid loading works because the roux limb of the intestine swells up, contracting and backing up any future food to come into the pouch. The pouch is very sensitive to this and the feeling of fullness will last much longer than the reality of how long the pouch was actually full. Fluid load before each meal to prevent thirst after the meal as well as to create that feeling of fullness whenever suddenly hungry before meal time. 

POST PRANDIAL THIRST 
It is important that the patient be filled with water before his/her next meal as the meal will come with salt and will cause thirst afterwards. Being too thirsty, just like being too hungry will make a patient nauseous. While the pouch is still real small, it won’t make sense to the patient to do this because salt intake will be low, but it is a good habit to get into because it will make all the difference once the pouch begins to regrow. 

URGENCY