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Pouch Rules

INTRODUCTION:
A common misunderstanding of gastric bypass surgery is that the pouch causes weight loss because it is so small, the patient eats less. Although that is true for the first six months, that is not how it works. Some doctors have assumed that poor weight loss in some patients is because they aren't really trying to lose weight. The truth is it may be because they haven't learned how to get the "satisfied" feeling of being full to last long enough.


HYPOTHESIS OF POUCH FUNCTION:
We have four educated guesses as to how the pouch works:

1) Weight loss occurs by actually "slightly stretching" the pouch with food at each meal or;
2) Weight loss occurs by keeping the pouch tiny through never ever overstuffing or;
3) Weight loss occurs until the pouch gets worn out and regular eating begins or;
4) Weight loss occurs with education on the use of the pouch.

PUBLISHED DATA:
How does the pouch make you feel full?

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 a while.
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, liquidity foods empty faster than solid foods. High calorie liquids will create weight gain.

EARLY PROFOUND SATIETY:

Before six months, patients much 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 preoperatively 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 AND MAINTAINING SATIETY:

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:

The first six months is the fastest, easiest time to lose weight. By the end of the six months, 2/3 of the regrowth of the pouch will have been done. That means that each present day, after surgery you will be satisfied with less calories than you will the very next day. Another way to put it is that every day that you are healing, you will be able to eat more. So exercise as much as you can during that first six months as you will never be able to lose weight as fast as you can during this time.

SIX MONTHS:

Around this time, our patients begin to get hungry between meals. THEY NEED TO BATTLE THE EXTRA SALT INTAKE WITH DRINKING LOTS OF FLUIDS IN THE TWO TO THREE HOURS BEFORE THEIR NEXT MEAL. Their pouch needs to be well watered before they do the last gulping of water as fast as possible to fill the pouch 15 minutes before they eat.

INTAKE INFORMATION SHEET AS A TEACHING TOOL:

I have found that having the patients fill out a quiz every time they visit reminds them of the rules of the pouch and helps to get them "back on track." Most patients have no problems with the rules, some patients really struggle to follow them and need a lot of support to "get it", and a small percentage never quite understand these rules, even though they are quite intelligent people.

HONEYMOON SYNDROME:

The lack of hunger and quick weight loss patients have in the first six months sometimes leads them to think they don't need to exercise as much and can eat treats and extra calories as they still lose weight anyway. We call this the "honeymoon syndrome" and they need to be counseled that this is the only time they will lose this much weight this fast and this easy and not to waste it by losing less than they actually could. If the patient's weight loss slows in the first six months, remind them of the rules of water intake and encourage them to increase their exercise and drink more water. You can compare their weight loss to a graph showing the average drop of weight if it will help them to get back on track.

EXERCISE:

In addition to exercise helping to increase the weight loss, it is important for the patient to understand that exercise is a natural antidepressant and will help them from falling into a depression cycle. In addition, exercise jacks up their metabolic rate during a time when their metabolism after the shock of surgery tends to want to slow down.

THE IDEAL MEAL FOR WEIGHT LOSS:

The ideal meal is one that is made up of the following: ½ of your meal to be low fat protein, ¼ of your meal low starch vegetables and ¼ of your meal solid fruits. This type of meal will stay in your pouch a long time and is good for your health.

VOLUME VS. CALORIES:

The gastric bypass patient needs to be aware of the length of time it takes to digest different foods and to focus on those that take up the most space and take time to digest so as to stay in the pouch the longest, don't worry about calories. This is the easiest way to "count your calories." For example, a regular stomach person could gag down two whole sticks of butter at one sitting and be starved all day long, although they more than have enough calories for the day. But you take the same amount of calories in vegetables, and that same person simply would not be able to eat that much food at three sittings - it would stuff them way too much.

ISSUES FOR LONG TERM WEIGHT MAINTENANCE:

Although everything stated in this report deals with the first year after surgery, it should be a lifestyle that will benefit the gastric bypass patient for years to come, and help keep the extra weight off.

COUNTER-INTUITIVENESS OF FLUID MANAGEMENT:

I admit that avoiding fluids at meal time and then pushing hard to drink fluids between meals is against everything normal in nature and not a natural thing to be doing. Regardless of that fact, it is the best way to stay full the longest between meals and not accidentally create a "soup" in the stomach that is easily digested.

SUPPORT GROUPS:

It is natural for quite a few people to use the rules of the pouch and then to tire of it and stop going by the rules. Others "get it" and adhere to the rules as a way of life to avoid ever regaining extra weight. Having a support group makes  all the difference to help those that go astray to be reminded of the importance of the rules of the pouch and to get back on track and keep that extra weight off. Support groups create a  "peer pressure" to stick to the rules that the staff at the physician's office simply can't create.

TEETER TOTTER EFFECT:

Think of a teeter totter suspended in mid air in front of you. Now on the left end is exercise that you do and the right end is the foods that you eat. The more exercise you do on the left, the less you need to worry  about the amount of foods you eat on the right. In exact reverse, the more you worry about the foods you eat and keep it healthy on the right, the less exercise you need on the left. Now if you don't concern yourself with either side, the higher the teeter totter goes, which is your weight. The more you focus on one side or the other, or even both sides of the teeter totter, the lower it goes, and the less you weigh.

TOO MUCH WEIGHT LOSS:

I have found that about 15% of the patients which exercise well and had between 100 to 150 lbs to lose, begin to lose way too much weight. I encourage them to keep up the exercise (which is great for their health) and to essentially "break the rules" of the pouch. Drink with meals so they can eat snacks between without feeling full and increase their fat content as well take a longer time to eat at meals, thus taking in more calories. A small but significant amount of gastric bypass patients actually go underweight because they have experienced (as all of our patients have experienced) the ravenous hunger after being on a diet with an out of control appetite once the diet is broken. They are afraid of eating again. They don't "get" that this situation is literally, physically different and that they can control their appetite this time by using the rules of the pouch to eliminate hunger.

BARIATRIC MEDICINE:

A much more common problem is patients who after a year or two plateau at a level above their goal weight and don't lose as much weight as they want. Be careful that they are not given the "regular" advice given to any average overweight individual. Several small meals or skipping a meal with a liquid protein substitute is not the way to go for gastric bypass patients. They must follow the rules, fill themselves quickly with hard to digest foods, water load between, increase their exercise and the weight should come off much easier than with regular people diets.

SUMMARY:

1. The patient needs to understand how the new pouch physically works.

2. The patient needs to be able to evaluate their use of the tool, compare it to the ideal and see where they need to make changes.

3. Instruct your patient in all ways (through their eyes with visual aids, ears with lectures and emotions with stories and feelings) not only on how but why they need to learn to use their pouch. The goal is for the patient to become an expert on how to use the pouch.

EVALUATION FOR WEIGHT LOSS FAILURE:

The first thing that needs to be ruled out in patients who regain their weight is how the pouch is set up.

1) the staple line needs to be intact;
2) same with the outlet and;
3) the pouch is reasonably small.

1) Use thick barium to confirm the staple line is intact. If it isn't, then the food will go into the large stomach, from there into the intestines and the patient will be hungry all the time. Check for a little ulcer at the staple line. A tiny ulcer may occur with no real opening at the line, which can be dealt with as you would any ulcer. Sometimes, though, the ulcer is there because of a break in the staple line. This will cause pain for the patient after the patient has eaten because the food rubs the little opening of the ulcer. If there is a tiny opening at the staple line, then a reoperation must be done to actually separate the pouch and the stomach completely and seal each shut.

2) If the outlet is smaller than 7-8 mill, the patient will have problems eating solid foods and will little by little begin eating only
easy-to-digest foods, which we call "soft calorie syndrome." This causes frequent hunger and grazing, which leads to weight regain.

3) To assess pouch volume, an upper GI doesn't work as it is a liquid. The cottage cheese test is useful - eating as much cottage cheese as possible in five to 15 minutes to find out how much food the pouch will hold. It shouldn't be able to hold more than 1 ½ cups in 5 - 15 minutes of quick eating.

If everything is intact then there are four problems that it may be:

1) The patient has never been taught the rules;
2) The patient is depressed;
3) The patient has a loss of peer support and eventual forgetting of rules, or
4) The patient simply refuses to follow the rules.

1) LACK OF TEACHING:

An excellent example is a female patient who is 62 years old. She had the operation when she was 47 years old. She had a total regain of her weight. She stated that she had not seen her surgeon after the six week follow up 15 years ago. She never knew of the rules of the pouch. She had initially lost 50 lbs and then with a commercial weight program lost another 40 lbs. After that, she yo-yoed up and down, each time gaining a little more back. She then developed a disease (with no connection to bariatric surgery) which weakened her muscles, at which time she gained all of her weight back. At the time she came to me, she was treated for her disease, which helped her to begin walking one mile per day. I checked her pouch with barium and the cottage cheese test which showed the pouch to be a small size and that there was no leakage. She was then given the rules of the pouch. She has begun an impressive and continuing weight loss, and is not focused on food as she was, and feeling the best she has felt since the first months after her operation 15 years ago.

2) DEPRESSION:

Depression is a strong force for stopping weight loss or causing weight gain. A small number of patients, who do well at the beginning, disappear for a while only to return having gained a lot of weight. It seems that they almost on purpose do exactly opposite of everything they have learned about their pouch: they graze during the day, drink high calorie beverages, drink with meals and stop exercising, even though they know exercise helps stop depression. A 46 year-old woman, one year out of her surgery had been doing fine when her life was turned upside down with divorce and severe teenager behavior problems. Her weight skyrocketed. Once she got her depression under control and began refocusing on the rules of the pouch, added a little exercise, the weight came off quickly. If your patient begins weight gain due to depression, get him/her into counseling quickly. Encourage your patient to refocus on the pouch rules and try to add a little exercise every day. Reassure your patient that he/she did not ruin the pouch, that it is still there, waiting to be used to help with weight control. When they are ready the pouch can be used once again to lose weight without being hungry.

3) EROSION OF THE USE OF PRINCIPLES:

Some patients who are compliant, who are not depressed and have intact pouches, will begin to gain weight. These patients are struggling with their weight, have usually stopped connecting with their support groups, and have begun living their "new" life surrounded by those who have not had Bariatric surgery. Everything around them encourages them to live life "normal" like their new peers: they begin taking little sips with their meals, and eating quick and easy-to-eat foods. The patient will not usually call their physician's office because they KNOW what they are doing is wrong and KNOW that they just need to get back on track. Even if you offer "refresher courses" for your patients on a yearly basis, they may not attend because they KNOW what the course is going to say, they know the rules and how they are breaking them. You need to identify these patients and somehow get them back into your office or back to interacting with their support group again. Once these patients return to their support group, and keep in contact with their WLS peers, it makes it much easier to return to the rules of the pouch and get their weight under control once again.

4) TRUE NONCOMPLIANCE:

The most difficult problem is a patient who is truly noncompliant. This patient usually leaves your care, complains that there is no 'connection' between your staff and themselves and that they were not given the time and attention they needed. Most of the time, it is depression underlying the noncompliance that causes this attitude. A truly noncompliant patient will usually end up with revisions and/or reversal of the surgery due to weight gain or complications. This patient is usually quite resistant to counseling. There is not a whole lot that can be done for these patients as they will find a reason to be unhappy with their situation. It is easier to identify these patients BEFORE surgery than to help them afterwards, although I really haven't figured out how to do that yet. Besides having a psychological exam done before surgery, there is no real way to find them before surgery and I usually tend toward the side of offering patients the surgery with education in hopes they can live a good and healthy life.

"Dummies" version rewritten by Sally Perez
Original article written by:
Mason. EE, Personal Communication, 1980. Barber. W, Diet al, Brain Stem
Response To Phasic Gastric Distention.
Am J. Physical 1983: 245(2): G242-8 Flanagan, L. Measurement of Functional
Pouch Volume Following the Gastric Bypass Procedure. Ob Surg 1996; 6:38-43

So the weight loss has been somewhat slow this week, but that's my fault!  I haven't been drinking all the water I need to - not because it won't go down, more because I'm lazy and was out of water bottles LOL  I also have not exercized one single bit so that doesn't help either.  I guess I need to get off my butt and plug in that Wii and Wii Fit I just bought and start doing something about it.  On the other hand, I have been super busy doing things around the house in preparation for Christmas.  Just putting up the tree was a 2 day ordeal..  I've also got my period - not like it's a complete full flow but just enough that I can't go without wearing "protection" and its annoying.. not to mention it has made me super tired all week.. The bleeding has been going on for a week and a bit now at the very least.  Hopefully it stops soon or I will need to make a doctor's appointment to get meds to make it stop!

I know that it will not always be like this, but losing 20 lbs in one week after surgery is simply incredible!

and it was yummy! he he!

It has been a week since surgery I have lost 20 lbs.  CRAZY!!!

I don't know what's gotten into me but last night I sat there and wrote Christmas cards.  I have NEVER done this. Usually, this time of year makes me depressed and grouchy and all around BAH HUMBUG!  I told my sister that I think Dr. Graber cut my Bah Humbug nerve during surgery LOL

This morning I put on size 18 jeans and zipped and buttoned them!

So here I am a week post-op already!  I feel GREAT!  (Tony the Frosted Flakes Tiger comes to mind just now! lol)

Anyway, I thought I would just update on the journey to Utica, surgery and all that jazz.

Mom, Hubby and I left Ottawa for Utica on Wednesday November 19.  We checked into our hotel rather late but we made it there.  November 20 my first appointment was at Faxton for pre-admitting.  Of course, we got lost LOL and went to St-Lukes instead.. was TOO easy!  The staff were really nice and I eventually made my way over to Faxton and took care of business.

My surgery was scheduled for 10:00 on November 21.  Scheduled to arrive at St-Lukes for 6:00 am for surgery prep.

We did some shopping at Wal-Mart and Mom and Hubby went for dinner at Delmonico's.  Strangely, even though I was on day 3 of liquids, I could care less that they were eating yummy juicy steak in front of me.  I had my strained broth and it tasted just as delish.  They both felt bad but I assured them that I was okay with it and that my not eating that stuff was just temporary; I WILL eat steak again, just NOT 24 ounces of it in one sitting!

We went back to the hotel after some more wal-mart adventures and I crammed in one last tall glass of cranberry juice, 2 jello and a bottle of water and it was time for bed.  Man, did those 5 hours of sleep ever go by quick!  Before I knew it, Mom was waking me up saying it was time to go! 
I showered, did my hair - yep, I HAD to do my hair LOL, got dressed and off we went.  Left Hubby at hotel since he is a little slow-going in the morning.  Mom sat with me through the surgery prep and left to get hubby before I was going to be brought down to pre-surgery.  They made it just in time!

The nursing staff at St-Lukes were absolutely wonderful - even though they were having a LOT of trouble finding a decent vein to put an IV in - I got poked at least 6 different times that morning before they were able to run one.

The time to go came and hubby and Mom followed as I was being wheeled to the first floor.  Everything felt SO surreal - I was ACTUALLY doing this...!!! I got a little teary when the nurse stopped the gurney and told them that this was the "last stop".  Hubby kissed me, Mom said good luck and off they went in one direction while I went in the other.  Oh my heart was heavy but there was no turning back.  I guess it was just a little bit of fear of the unknown!

It was very cold in the surgery holding area so I was given extra blankets. Dr. Graber came by and I met his PA and some of the other staff who were going to be assisting in my surgery.  It wasn't very long that they came to wheel me in to the O.R.  I loved how instead of having me transfer onto the operating table they had their inflatable hover mattress LOL that thing was awesome! hehe

I was moved onto the operating table, the lady removed the hose to deflate the mattress and I vaguely recall the anesthesist putting the gas mask on my face and poof, the lights went out, so to speak!

I do not recall a single thing about recovery to be quite honest.  Obviously I woke up because I am sitting here writing about the adventure but I don't remember being wheeled out, no clue how long I was there for, nor do I remember being wheeled from recovery to my room on the 2nd floor either. 

I have a vague recollection of seeing Mom and hubby in my room once I made it up there,but I was SO doped up (Drugs are GOOOOOOOD) that I barely realized they were there.  I honest to G-d felt NO pain!

I spent the first few hours dozing in and out of consciousness and taking wee small sips of water. Did I mention I LOVE Percacet?!

At one point the nurse came to help me out of bed to go pee - oh boy was I EVER dizzy and doped up!  I felt as though I was going to be sick so back to bed I went and she gave me a shot of Zofran, anti-nausea medication and I was out like a light again! 

I remember having brief moments of lucidity here and there but mostly I wanted to sleep!

Saturday morning was bustling and busy in the hospital - there were a bunch of student nurses on the ward.  Mine was Yelena and, she was very nice, for the most part!  At one point, she offered to get me fresh juice and water.  I had been drinking diluted apple juice with crushed ice and water.  Well, she brings the juice, I pour some in my sipper and swallow. OWIE!! She hadn't diluted the juice -it was pure.. OMG the cramps... strangely it hurt right away!  I didn't drink juice for the rest of the day!  I pointed out to her that gastric patients cannot consume THAT much sugar and that juices must always be watered down.. she felt SO bad, poor thing... I know it was an honest mistake.. I'm sure she'll make a great nurse though - she even offered to change my bed sheets LOL

I took my first shower and I must say that in spite of the effort it took, the hot water felt amazing!! I felt human again LOL  Brushing my teeth after surgery was almost heavenly! I mostly laid there and enjoyed the Percacet induced sleeps - the drugs were particularly useful in drowning out the noisy guy across the hall screaming day and night for his coffee and "ass hole" like he had Tourrette's or something. 

Nightime brought Jim the male nurse who was one of the nicest guys I have ever met.. he was very chatty and attentive - not that the female nurses weren't but he talked a lot.  I took a walk around the floor in the hopes of passing some gas as I felt bloated but not much happened.  I visited my surgery sista, Chris D and we chatted briefly before I went back to bed with Percacet!

Sunday morning, Valentina the crazy nurse came into my room at 7 and started opening the blinds and pulling my blankets away to wake me up!  I looked at her like she had 3 heads and told her that I was NOT waking up or getting up, that I took Percacet at 4:45 and I wanted to SLEEP!! She got the hint and left but she kept coming back... UGH she was a pain in the butt!  I know, she was only doing her job but geez woman, can't you see I'm drugged up and just want to snooze?! 

I eventually got my butt out of bed and made my way to the shower again, changed my pj's and settled back into bed.  Eventually Mom and hubby came to visit and shortly after, handsome Dr. Fitzer came by to talk about discharge.  I was FREE to go! Yippee!  I quickly got dressed, completed the appropriate paper work, got my post-op instructions and a gas pill for the road and we were out of there!

We went and did a quick bit of shopping and they brought me back to the hotel to settle into bed.  I took some Gas-X strips and watched a movie on the Hallmark channel.  Finally I started to fart!

Evening and sleep were uneventful though it was a bit hard to get out of the hotel bed..

November 24 - got ready and checked out.  Stopped at Dr. Graber's for post-op release visit.  Had already lost 10 lbs since surgery!!  Was given the green light to leave.  We did a bit more shopping and headed home!

Stopped at Cracker Barrel on the way home - I knew I couldn't eat but I hoped that they had soup so I could have broth.  Well, the waitress tried her best but the broth she brought me was way too salty AND there was like 10 lbs of fat floating on top.. I ate a spoonful or two and decided I just couldn't risk it - I was afraid it was so fatty I might dump on it.  In the end, she saw that I didn't eat it and she asked why so I told her and she removed it from the bill because she was actually charging us as though I had had a bowl of soup!

To make a long story short, I sipped sipped sipped my way back to Ottawa and was never so glad as when I set foot in my house! There really is no place like home!

To ignore the risks of WLS is to ask for them to happen to you, in my opinion.

There are a lot of complications possible with surgery in general and WLS specifically. The complication that bothers people the most seems to be regain or lack of weight lost. This is often a taboo subject on this board because so many newbie post ops simply can't deal with the major life change they are going through and think about the possibility of it being all for naught.

I have often read about people who are post op, have regained and are shocked it happened to them. They regularly say they had no idea they could regain or regain all of their weight back. They often say their surgeons sold them on surgery by telling them all of the good things and none of the bad. I was not in this situation. Everyone in my surgeon's office made it very clear that WLS is NOT a miracal or magic. I was left with the impression that their job was to make it possible for me to lose weight but my actions would determine how much weight I would lose and how long I would keep it off.

I hope you all are in the same situation as I and are going into, or have gone into, WLS knowing the great responsibility that is yours and yours alone to keeping your weight at a controlable and healthier level for life. There is no surgery with 100% success. Its simply not possible. Its up to you to learn what your food issues are be them mental, physical, hereditary or environmental and do everything you can to fix them while using surgery to lose weight.

Its also up to you to learn the nutritional issues post weight loss surgery and stay current with the medical infrmation available to stay healthy. Following the post op nutritional and supplimental regiments is as important as losing weight. Its no fun fitting into a size 4 but have chronic pain and troubles due to severe calcium deficiency. Doctor's do not know everything there is to know about obesity, WLS and long term affects of both. The field is still evolving as new information is discovered. This is why post op support groups either in real life or like OH are essential to long term success. People sharing their personal experiences and research will help us all.

My surgeon had lists of patient resposibility to get the weight off and one to keep it off. In case yours didn't Im posting them both here. Please feel free to add your own personal discoveries to staying successful post op. I dont agree with all of these for ME but they are the basics for all of us and a great starting point for those people who are less informed about how to lose weight and keep it off with RNY.

snuggly hugs
PK

10 Golden Rules for Weight Loss Surgery Patients

After surgery, you need to make changes in your eating habits in order to reach your desired weight loss goals. These changes will also help prevent pain and vomiting. It is very important for you to develop appropriate eating habits to prevent ENLARGEMENT of your NEW STOMACH.

The following 10 rules will help you to reach your goals and achieve the best possible results with your Weight Loss Surgery. Your commitment to following these 10 guidelines is critical.

1. Eat only three small meals a day

   Weight loss surgery creates a small stomach pouch that can hold only half a cup of food. If you try to eat more than this at one time you may become nauseous and/or vomit. If you routinely eat too much, the small pouch that has been created by your weight loss surgery procedure may stretch and cancel the beneficial effects of the operation. Frequent vomiting can also cause complications such as stomach slippage (band cases) or burst stomach (bypass cases). You need to learn how much your stomach pouch can hold and not exceed this amount.
    

2. Eat slowly and chew food thoroughly

   Once you are beyond the initial four weeks and started on some solid food, be certain to CHEW YOUR FOOD until it reaches a mushy consistency (AT LEAST 40 CHEWS PER MOUTHFUL). Take your time eating each meal (30-45 minutes) and swallow small bites of food. Swallowing chunks of food may block the opening of your pouch and prevent the passage of food.
    

3. Stop eating as soon as you feel full

   Sometimes it takes time for you to become aware of the signal that your stomach is full. If you hurry your meal, you may eat more than you need. Try to recognize the feeling of fullness and stop eating as soon as you feel full.
    

4. Do not drink while you are eating

   After 2-3 months and for the rest of your life, your operation can work only if you eat solid food. If you drink at mealtimes, what you have eaten becomes liquid. This would defeat the purpose of the weight loss surgery. You should not drink anything one hour before and one hour after your meal.
    

5. Drink a lot during the day

   You need to drink large amounts of liquids every day (at least 6 big cups of liquid) in order prevent dehydration, provide fluid for urination, and in order to excrete the waste fat that you are loosing. Remember to drink only water, tea or coffee (without cream) and keep your food and drinks completely separate.
    

6. Drink only low-calorie liquids

   Drinks, including those containing calories, simply run through the narrow outlet, called the stoma, created by the weight loss surgery. Drinking high calorie liquids will decrease your ability to lose weight, even if you follow the solid food diet.
    

7. Six months after your surgery DO NOT EAT BETWEEN MEALS

   After each meal, do not eat anything else until the next meal. Eating snacks between meals is one of the major reasons for failure to lose weight.
    

8. Eat a balanced diet consisting of fresh food

   With your weight loss surgery you can eat only small amount of food. Consequently, your diet needs to be as healthy and as balanced as possible. Eating food from each of the four food groups will provide adequate amounts of protein, vitamins, and minerals. Each meal should be high in protein and vitamins and include fresh vegetables, fruit, meat, and cereals. Foods high in fat and sugar are not acceptable. You may eat apples and oranges but try to avoid orange juice and apple juice. Avoid foods that are high in fiber, such as asparagus. High fiber foods can block the stomach. Make sure to consult with your doctor and nutritionist in order to establish a well balanced diet.
    

9. Exercise at least 30 minutes a day

   Physical exercise is critical to the success of your weight loss goals. Exercise consumes energy and burns calories. That is the key to losing weight. Moreover, exercise can help improve your general health. You can start with simple exercises such as walking or swimming. With weight loss, it will become easier to exercise. Consult your physician to confirm the right specific experience plan for you.
    

10. Self-control and high motivation

    You have taken a major step toward reaching you weight loss goal by choosing to have weight loss surgery. You should feel confident in continuing your weight loss journey by exercising self-control and following these basic guidelines to success.

Your greatest weight loss will occur in the first 6 to 8 months after the gastric bypass procedure. Most patients will plateau after 12-18 months, and after this, additional weight loss will be difficult. There are 8 cardinal rules that you must follow in order to attain a weight that is close to your ideal body weight:

1. Meals larger than 1 cup may result in weight gain.
2. Consumption of an adequate amount of liquid, preferably water, is crucial. Patients should consume a minimum of 1 1/2-2 liters of liquid per day. This should be done slowly and throughout the day. Never drink more than 2 oz. of liquid in a 10-15 minute period. To prevent dehydration, this amount should be increased by 10-20% when the weather is very hot and humid.
3. You should have 3 regular meals and 3 small snacks per day (see Seven-day menu). "Grazing" on small amounts of food throughout the day will sabotage your weight loss and result in the inability to lose an adequate amount of weight.
4. The primary source of your nutrition should be protein. 65 to 85 % of all calories consumed should be protein-based (eggs, fish, meat, etc.). Carbohydrates (bread, potatoes, etc.) should make up only about 10%-20%, and fats (butter, cheese, etc.) only 5%-15% of the calories that you eat. A diet consisting of 1200 calories and about 70 grams of protein should be your goal. Hair loss, cracked nails, and defective healing and immunity are just some of the side effects of inadequate protein consumption (not to mention difficulty losing weight).
5. Never drink liquids when eating solid foods. Liquids should be avoided for a period of 30 minutes before and 60 minutes after eating solid food or meals.
6. Avoid foods that contain sugar. Not only will they slow your weight loss, but they will make you sick! Sugar causes "dumping" in patients who have had the gastric bypass procedure. Dumping Syndrome occurs when sugars go directly from you stomach to your small intestine, causing heart palpitations, nausea, sweating, abdominal pain, and diarrhea. Dumping Syndrome occurs also when food is "dumped" too rapidly in the small intestine.
7. Stop eating or drinking when you begin to feel full. "Stuffing yourself" may cause your stomach pouch or stoma to stretch - or worse, burst - causing long-term problems and complications.
8. Avoid alcohol and carbonated beverages.

So I am back on the surgery bandwagon.  Unfortunately, we miscarried. While it is hard to understand how such a precious gift could be taken away from us before we even got to bring it into the world, DH and I both believe that things happen for a reason.  That said, when I get pregnant again, I will be a healthy weight and baby will have all the best chances in the world.

 I haven't been as active on the boards as much as I usually am.  There is a perfectly good reason.. When I sent in my OHIP papers in July, I told my Mom that the last thing I needed now was to get pregnant! Well! Who knew that all it would take was me changing the focus from baby-making to something else..  I recently found out that infertile little me is pregnant.. I am pregnant... yes.. pregnant for the very first time!

Ironically, when I saw Dr. Graber for my consult, we talked about the possibility of being pregnant and I assured him that there was NO way I was pregnant, that DH and I had been trying for 19 months without success.. and we discussed how surgery increases fertility and to not get pregnant for 18 months post surgery.. Hmph! I'd even done a pregnancy test prior to beginning the patch to quit smoking - it was negative...

On the day I found out, I cried a little - don't get me wrong - I am absolutely thrilled to become a Mom; heck, it's what I've wanted for ever  but at the same time, I was sad because I also really want the WLS.  In fact, I was intent on being as healthy as could be when I would become a Mom.

That being said, I haven't cancelled my surgery yet as I am still in the first trimester and consider this pregnancy to be very fragile. Once I see the OBGYN in a couple of weeks and he confirms that all is well with my foetus, I will then cancel but right now, I don't feel pregnant, don't look pregnant and I just want things to stay the way they are.  I guess it will really sink in and feel "real" once I hear the heartbeat sometime soon..

I have always been a firm believer in things happening the way they do for a reason - G-d only gives you what you can handle.. so this is it for me.. but I will be back - I'm not giving up on the idea of WLS; it's just delayed for now.  I have every intention of being there for my dear friend DK0429 (Joanne) as her angel and I will be lurking on the boards to keep up with what is going on..

When I got to Dr. Graber's and told them Mom had been unable to come, I was told that the consults were now being booked for early-mid December and to check in with them on my way out, that they would book her a new consult date.. Anyway, they must work miracles there because when I left, the card they gave me for Mom said November 4, 2008!! That is just awesome!

She just called me a couple of minutes ago to let me know that she also got her OHIP approval!! Whooo! This is really happening for both of us now!