Revision causing bigger than normal RNY pouch?

 
Anyone else have this?  

I was quite surprised at my 4 mth follow up appointment to find out that I have a larger than normal RNY pouch  what?!?!?!  

This came up because I was telling my doc how much my appetite and hunger pangs have increased which has been really worrying me.  He told me that that was normal as I have a bigger than normal RNY pouch due to the extensive scarring and damage to my stomach tissue caused by the LapBand I had for 6 years.  He also remembers having a very hard time visualizing the bottom of my esophagus and seeing that that is full of scar tissue as well from the reflux caused by the LapBand.  

He said that my stomach is significally smaller than my original stomach, but that my pouch is wider and longer than a normal RNY patient because he had to navigate around the scar tissue and had to get to an area that the staple gun would penetrate so that I didnt have any leaks which makes sense, but just was not what I was expecting to hear.  

Unfortunately, the pouch size is not noted on my OR report so I have no idea how big it is and at this point, he can't remember how big he ended up making it.  I would venture to guess that I'm somewhere between a RNY pouch and sleeve-sized stomach.

So, any suggestions on figuring out how much I should be eating at 4 1/2 months (18 weeks) out?  I'm still hungry after a "normal" RNY portion, but I don't want to eat too much and run into problems with that.  I also don't want to start "grazing" between meals.  As it is, I'm supposed to be eating 6 small meals a day to keep my blood sugars at a good level.  Protein shakes no longer fill me up, they just go right on through, so does cottage cheese, which was my biggest "go to" food.

I guess what I am trying to figure out is how much to eat so I am not still hungry but so that I will continue to lose and not over eat and stretch out my pouch. 

I am, however, making sure I am getting in all of my vitamins and supplements, I haven't slacked on that because I know if I do, especially burning the candle at both ends, I will get sick. 

For the last few weeks I have been bouncing between 183 - 187 and just can't seem to get below 183.  I KNOW I am not done losing and that some of this "stall" for lack of a better word is MY fault because I have not been exercising and have only been getting in about 50-60 grams of protein a day if I'm lucky.  

I'm working both jobs right now, and covering for a lady whose husband is home on Hospice, so I am working 12-14 hour days and until she comes back to work, exercise really isn't realistic.  I'm dead tired at the end of the day and can barely drag my butt out of bed in the mornings, and my crazy schedule is why I'm not exercising now and not eating the way I should be.  

Oh yeah, I asked him about my ideal weight and he said I could go as low as 131, but he would like to see me at 145-150 lbs.  He said he would be happy with that and he thinks I will be too.  

I am open to suggestions!  

  

It seems odd to me that he doesn't know how big he made your pouch and that he didn't include that in the OR report.

Anyway, I bet this is a common problem with revisions from lap band because the band often causes a lot of scar tissue.  However, from what I've read, the size of the pouch doesn't have as big an effect on the success of RNY as you might imagine.  If your pouch is much smaller than a "normal" stomach, you should have pretty good restriction.

I think what you'll need to do is to use your tool carefully so you get the best results from it.  Dense protein will stay in your pouch longer and make you feel full longer.  Protein shakes and cottage cheese will slide through the pouch easily, no matter what size the pouch is.  Make sure you wait at least 30 minutes after meals before drinking so you don't wash food out of your pouch.  You might want to wait a bit longer than that, maybe up to an hour.

Between meals, drink as much as you possibly can.  Really limit the starchy carbs and sugar because those foods tend to make you hungrier and cause food cravings.  If you really need a snack between meals, go for very low cal options like baby carrots or other raw veggies.

 
Thanks, Kelly!

Yeah, I was surprised my pouch size wasn't listed in the OR report; I thought that was standard, but I guess not.  And you are right, from what he said, this is a very common situation that occurs in revisions, especially for people who had the LapBand.  

I'm definitely eating A LOT less than what I used to eat pre-op, I just can eat more than I thought I should be able to after having RNY a few months ago.  I think you're right too, that I need to focus on eating more dense protein as that helps regulate my sugar as well as it does fill me up more, and I will stick to RNY portions and drink extra fluids in between. 

I've only been waiting 30 minutes after I eat to start drinking, so waiting longer is a good idea.  Maybe with the bigger pouch I am washing food out by only waiting 30 minutes to drink.  It's certainly worth trying!

Thanks for the suggestions!  

I don't mean this to sound harsh, but I am curious about your statement that you are still "hungry" after a normal RNY portion.  Even when we had our natural stomachs and natural sense of hunger, even a small portion of food would eliminate the actual hunger sensation.  The same should happen with the RNY.  Once there is something of reasonable size for the stomach/pouch to process, the hunger should cease.  This makes me wonder if the "hunger" is psychological rather than physical.  Many people who are obese (myself included) are/were not very good at interpreting signals of hunger, thirst, and satiety.

In any event, for everyone (regardless of pouch size) with WLS of any kind, ultimate success comes down to controlled portions and healthy food choices.  Your eating habits contribute far more to your success than your pouch size.  You may need to measure portion sizes until you get used to what a proper portion should be. You may also need to eat smaller, more frequent meals.  You might also benefit from drinking a lot of water (or whatever liquid) shortly before you eat so that your intestines are full of liquid (which will increase your sense of fullness before you even take a bite of food).  It is generally referred to as "water loading", but if you do an Internet search, be aware that some sites that talk about it are for people with normal anatomy and so some recommendations may not be appropriate, but the idea is the same.

lora

Hi Lora, 

I don't think you sound harsh at all, I welcome your input! 

Pre-op, I never felt not "hungry" until I ate so much that I made myself feel sick.  The best way to describe it is that I felt like my "off switch" didn't work.  Not feeling "full" after a RNY portion could very well be psychological and maybe I still am not really interpreting what my body is telling me correctly.  I certainly wouldn't rule that out at this point, especially as I am trying to re-learn how to eat correctly and what my body is telling me.  

Up until the last few weeks, I have been feeling full/satisfied with RNY portions.  Now, however, if I eat 1/2 cup of something, even denser protein, 15-30 minutes later I feel "hungry" like I could eat again.  Maybe it's not hunger at all and it's thirst.  

I think you and Kelly are right and more fluids will help, especially if I really am just thirsty after I eat and not still hungry.  I am going to try waiting 45-60 minutes after I eat to drink and see if that makes a difference, and I will start pushing more fluids and see how that works. 

I just don't want to screw this up and I want to use my tool in the most effective way that I can, which is why I was posting.  You guys on here are my best resources!!!

The pouch size thing kinda freaked me out and I was panicking, your and Kelly's responses have helped a lot, thank you.  I was stuck on my pouch size and I shouldn't be; I need to keep my focus on my food choices.  

 The Cottage Cheese Test

1. Purchase a container of small curd low-fat cottage cheese.
2. Begin the test with a full container of cottage cheese, and perform the test in the morning before eating anything else. This will be your breakfast on that day.
3. Eat fairly quickly until you feel full (less than five minutes). Note that the small soft curds do not require much chewing. You are eating rapidly so you will fill the pouch before there is time for any food to flow out of it.  After eating your "fill" of cottage cheese, you will be left with a partially eaten container that has an empty space where cottage cheese used to be.
4. Measure the volume of cottage cheese you have eaten by filling a two cup (16 fl.oz.) measuring cup with water. Pour water into the container of cottage cheese until the water level rises to the original top level of the cottage cheese.
5. The amount of water poured into the container is the functional size of your pouch.

Dr. Flanagan's research indicates that the average volume of the mature stomach pouch, measured by this method, is 5.5 ounces (163 ml). Additionally, he reached the conclusion that, "sizes ranging up to 9 ounces have NO IMPACT on the person's success in weight loss". This means that unless your pouch holds a greater volume than 9 ounces (267 ml), the exact size of your pouch is nota critical factor in whether or not you can lose excess weight and then manage your weight as time progresses.  

It is just my opinion, of course, but it seems silly to waste almost an entire container of cottage cheese to determine pouch size (and, even if you eat quickly, I am not convinced that cottage cheese, which is a slider food, doesn't start to exit the pouch) when there isn't anything that can be done to change it anyway (especially in the case of the OP).  As you pointed out, even a pouch that is almost twice the "average" size doesn't make much difference in losing weight and maintaining the loss (that what you choose to put into it matters much more).

Lora

 
That's interesting.  I've never heard of this before!  Thanks for the info.

When you say that the size of the pouch is not on the op report, is that the doctor telling you that or do you have a copy of the report. I have a copy of my report, you can request one from the hospital.

Lyn

 
Hi Lyn, 

I spoke with a lady in the office and asked her to check my report and let me know what my pouch size is and she said it is not listed anywhere on the report.  I am in the process of getting a copy of the OP report for myself.