Difficulty Eating during the 'Window of Misery'

I had a patient in the office today about 8 weeks out from her laparoscopic Roux en-Y gastric bypass. She had lost about 50 lbs and was concerned about having more difficulty eating some solid foods than she seemed to have just a few weeks ago. I explained the symptoms she is experiencing are fairly common for people 6 to 9 weeks after a gastric bypass. Some people call this time “the window of misery”. Although most patients will not be bothered by symptoms during this period of time, others will experience temporary difficulty.

When a gastric bypass operation is first performed I use a 25 mm circular stapler to make the connection between the gastric pouch and the small intestine so the outlet size is consistent. Initially the connection is about the size of your thumb and there is minimal resistance to food and drink. The connection heals by the body laying down scar tissue. As the healing process continues over the next several weeks, more scar tissue forms and the scar contracts making the outlet of the pouch become smaller. Eventually between 6 and 9 weeks, during the “window of misery”, the size of the outlet is only the size of the tip of your little finger or even less.

Because the outlet is so much smaller there is more resistance to the food passing through the new opening. Therefore to get food to pass it takes longer and the particle size may need to be reduced. In fact if a patient continues to try to eat and drink as they have in the first few weeks after their operation they can make themselves miserable. If they eat faster than the pouch can empty, the food and drink will back up into the esophagus and the will experience a squeezing pressure in their chest from the contractions of the esophagus trying to push the food through the smaller opening. This pain in the chest after eating means the patient is eating faster than the food is able to leave the pouch.

Fortunately, after about 9 weeks the scar will slowly mature. As the scar softens the outlet will become larger again allowing more food to pass more quickly. Over time the symptoms will become less frequent.

Nevertheless, even at 6 months it is likely that a patient will occasionally have difficulty with some foods such as bread, chicken or steak. Sometime between 6 and 12months even these foods will pass more easily.

About once a year in our practice the narrowing becomes so small it is difficult for anything to pass. This is called an anastomotic stricture meaning there is a severe narrowing or stricture at the anastomosis or connection between the pouch and intestine. If this happens the patient should have an upper endoscopy and a special balloon is passed to dilate the opening. After this is done the patient will be able to eat and drink normally the same day. This procedure can be performed without the patient staying in the hospital overnight.

But for most people if they are patient and take liquids with small particles until after 9 weeks following surgery they will not need a dilation and will get through this time without difficulty.