Understanding the Pouch

Language Translation Center - LTC - artist: Marijana Zaric.

I replied to a post on OH about how the pouch works and why it's a tool that we can use for the rest of our lives. There are always a lot of questions about stretching the pouch and damaging the stoma... and I hope this helps explain all those things a bit.


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Your original stomach (before surgery) could hold up to 4 liters of food (that's 16 cups!!). Your new pouch at the time of surgery was about 1oz and could hold about 2oz of food. Your surgeon made your pouch out of the least-stretchy part of your stomach, so it's difficult to stretch it. 


BUT... Our pouches will GROW over time. 


Yes, it's a living organ and your body tries to compensate for the rearranging we did to it and it will grow to help get in as much nutrition as possible. A mature pouch is anywhere from 6oz to 9oz in size... and can naturally stretch to hold up to 12oz of food at a time. A pouch reaches maturity at about the 2-year mark. By 6 months post-op your pouch has grown to about 2/3 of it's maturity level. You're nearly a year out. So your pouch is no longer 1oz in size ... it's more like 3oz or 4oz right now. 


Studies have shown that the size of your pouch has very little to do with your overall success with weight loss. Your success has more to do with how well you follow your eating and exercise plan and how well you follow the "rules of the pouch." 


Also remember that your body immediately begins to compensate for the surgery (this is called intestinal adaptation). Once your body realized that a portion of your instestine has been bypassed and you aren't absorbing all the calories you're eating, it goes to work to "fix" itself and become more efficient at absorbing as many macro- and micro-nutrients as possible. 


Micro-nutrients are vitamins and minerals and within the digestive tract there are specifically assigned points of absorption for each. To understand better about where nutrients are absorbed in the small intestine, see this diagram of the digestive tract. Unfortunately the body will never be able to repair this portion of bypassed intestine, so we will always malabsorb the micro-nutrients that were normally absorbed in those intestinal spots. Over time the body may be able to passively absorb some of those bypassed vitamins ... for instance, there are three main points of absorption for  Vitamin D and two of them are bypassed. But the one remaining point of absorption may, over time, become more efficient at it's absorption duties and make up for some of the work that the other two points are no longer doing. But some bodies don't become efficient enough to do the extra work.  This is the reason we'll take vitamin supplements for the rest of our lives.


Macro-nutrients are protein, carbohydrates and fats - what calories are made of. This is where adaptation comes in. Your intestines grow additional villi along the intestinal wall -- the little fingerlike tenticles that grab macro-nutrients/calories as food passes by. No, we won't ever replace those first 100-150cm where various vitamins are absorbed, but the body figures out how to absorb all the calories we eat eventually. Adaptation begins immediately but it takes about 2 to 3 years for your body to fully adapt and being absorbing all 100% of our calories again. By the 2-year mark you're likely absorbing every single calorie you eat. (This is the case with DS folks too!)


As for not feeling full -- that's perfectly normal. There is a complex network of nerves in our stomach - big nerves and little nerves.  And many of those nerves were cut during surgery while forming our new stomach pouch. These are the nerves that signal to our brain when we are full/hungry/etc. In some people those nerves repair themselves as early as 3 months post-op, but for others it might take 18 or 24 months for them to start working again. And often they don't have the same "signal strength" as they once had before surgery. This is why it's so important to always measure/weight the food we eat. 


By ALWAYS following the rules we were given, we will always be able to effectively use the tool we have. One of the biggest rules to follow that protects our pouch from abuse is:


NO drinking with meals -- that's a big rule that so many people get lax on the further out they get. Once we fall back into that bad habit, we have basically rendered our tool useless. But once we stop drinking with meals, we realize the pouch tool still works just fine. 


I firmly believe the tool continues to work for the rest of our lives. As long as we protect it and be kind to it. But understanding that it grows, matures and changes is very important when you have to adapt your behavior to what's going on inside your body.


~Pam