Search the Community

Well since I was in Mexicali, they don't do major pain meds like Dilaudid; they do the initial morphine spinal (an odd pain medication delivery system to me, but whatever) and after that you get under the tongue pain meds which aren't very effective. Most of my discomfort was from gas, bloating, queasiness, and everything associated with stomach upset rather than real PAIN. Dilaudid is a heavy-duty morphine pain med; I had it when I broke my leg as that was the appropriate pain relief medication for that situation. I had to have surgery to fix my fracture (and thus began my 10 year spiral of weight gain, but that's another story). For this type of surgery, in my humble opinion Dilaudid is way over-kill. Not that I would have turned it down, mind you, but apparently such a heavy duty drug is not the protocol at Hospital Almater.:laugh0: The liquids are going. I use a straw. The first 5 days (that's all I got so far) it still hurts a little when I drink. That supposedly goes away after a week according to Dr. Aceves. Hope so. I am sipping, not gulping (as if!) but I still feel that spot that the Water hits when it goes down, especially in the middle of night when my pump is not primed like during the day, if you know what I mean.

Hello all! Hard to believe it's been one year this week! Crazy! Wanted to see how everyone is doing. I bottomed out at 209 in August while working on my 5K training (the race was in October). After November, I stopped running, and did elliptical inside more. November and December were my first two months post-op when I GAINED on average! Yikes! I had been averaging 215 in August, September, October...a little up some weeks, a little lower on others. In November, I averaged 216 and then averaged 219 in December!!!!!!! I started off 2014 at 220. It's a little disconcerting to see how it can come back, but not surprising. Work, life, holday stress, etc. Food's been our "friend" for so long. I joined a '365 miles in 365 days' group to recommit to activity (which, truthfully, I never gave up on, which makes the weight gain even scarier!). Now, I just need to focus on the head battle. I'm still far below my own goal, far below my nut's goal, still wearing clothes in the size range from high school, but this monkey never will leave our backs...the modest weight gain has been a mixed blessing in some ways to recommit to this path we've chosen. Rock on January sleevers!!!!

Ive taken diet pills off and on during my banded years. When I ve noticed a weight gain (+3-5 pounds) I'll taken them for a week or so till I can get my eating under control. I keep a bottle of tenuate (oblong tablets) on hand for these situations! I -always- break the tablet in half, I cant stand the 'high' feeling the diet pills give me. For me, 1/2 tablet works fine and goes through the stoma with no problems. Good luck!

Ah ha, that explains my weight gain. It's the trophy! I'm not setting it down though, too many people trying to get their hands on it.

I spoke at a lapband info night last week just to give my experience as someone who's been successful with it. Before i got up, my surgeon spoke for about 40 minutes and he made a big deal about how the lapband provides satiety and lack of hunger and that is how it is supposed to work primarily - more so than restricting what you eat. I thought "wow, that hasnt been my experience". Early on, I had that. For about six months. I lost interest in food, I mean, I enjoyed what I ate, but I wasnt hungry, didnt have head hunger, never felt physical hunger. That didbnt last for me. I have a normal appetite, normal hunger levels and a fair degree of head hunger these days, I've just learned to deal with them. So yes, i do get hungry and i very often just want to eat for no particular reason. Perhaps more fill would solve it, but I'm at a healthy weight and dont need to lose, so I havent sought that out. I'm about to get unfilled in about an hour becuase I'm having another surgery next week. Part of me so doesnt want to do that, I'm terrified of rebound hunger and weight gain but a part of me is also VERY interested as to how much hunger/restriction/control this band is providing me. I'll report back!

Well Here I am 4 days post op and I have to say that today is by far my best day. Again no problems with surgery, but I highly recommend not getting teeth done the same time..LOL. its like a double whammy on your body. This morning was the the first that I woke up without that excruciating pain in my jaw, and i was actually able to talk without feeling like my jaw was going to explode. I have shied away from the boards because of this. As far as the surgery, I feel wonderful!. I am unsure how much fluids I am getting down cause I keep forgetting to track it, but I do know it's enough as my urine is running very clear. I have no head hunger, but there are times that my tummy lets me know its time to feed it more fluids. I am very sorry for not updating as soon as I should have been, as I was taking all the time I needed to feel better in my mouth. The weight gain after surgery is horrid. i was down 14lbs before surgery from 322 to 308. The day I left I noticed I was weighing almost 2lbs heavier which I figured was water retention from nerves. Day of surgery i did weigh 310 on doctors scale. Day I got home Wednesday the 8th I weighed 319 lbs. I knew and read over and over about retaining fluids after surgery, but I guess you never really expect it or believe it until you see it. today, day 4 I am finally dropping a few, but I am staying off the scale until my weekly weigh ins. I have not tried too many different drinks so to speak. I am living off water and some gatorade. I did try some watered down apple juice, but in all honesty that gassed me up so bad. I am hesitant to try skim milk yet, but I sure am craving it. Today was the first day that I tried some chicken broth- again had to dilute it. I am not eating any jello as I am worried about jaw pain and not being able to chew very well. Everyday that passes is another day of my journey!

you are worth the changes we need to do. we became obese because we never said stop to food, right? now you have a new challenge, you are worth it. take one step at a time, take a breath and see what happens. walking will help you get your mind off the weight gain, start now. keep in touch with the forum. we want to see you succeed, you can do it. drug addicts and alcoholics stop using, so can you. I have been drug and alcohol free for almost 29 yrs. if I had looked at stopping everything past one day or even one hour at a time in the beginning I would never have made it. the best thing I did was get and use support of a group. I trusted others who had gone through the same issues, it works. smoking is not good for you, it is a drug. take care of you, you are worthwhile!!!

What a great decision your mom has made. The surgery will be perfect to get her back on track to a healthy lifestyle. I am a cancer survivor as well thats why I have short hair, I have 14 months of hair growth. I know exactly what you mean about not being able to move and all of the medication having an affect on weight gain. In the last 2 months, I am starting to feel like myself again, pre-cancer. It's great! Thanks Libra and Pelerojo for the kind words. Btw, I miss my cartoon chic too! LOL.

Yes, all the doctors and published side effects of Coumadin will proclaim that it does not cause weight gain. It can cause boating, which may account for some Water weight, but not "real" weight. However, as a retired nurse, I have heard dozens upon dozens of patients complaint of weight gain after starting Coumadin. Anything from 10 to 40 pounds. And they couldn't lose the weight. Nobody (that I know of) ever did any sort of body composition studies to confirm if it was fat gain or Fluid gain, but there were too many complaints to ignore the fact that the numbers on the scale went up for a lot of Coumadin patients. Well, that's wrong, the doctors had no problems ignoring it. As a new WLS patient you could just be experiencing a normal stall, but some of it could be due to the Coumadin. In any case, all you can do is stick on plan and maybe stay off the scale for awhile. Take measurements and pay attention to NSVs and how your clothes fit. Do they know how long you will have to take the medication?

Thank you so much Smith.99. This is exactly why this particular forum was started. We really appreciate you coming back and sharing your experiences with us honestly. There have been many on this forum and others who have been trying to decide which weight loss procedure or surgery would be best for them. I am sure you researched as much as everyone else did before deciding and people in these forums were probably the best source of information because they have been through it and can give you a real life account. Your honesty is so valuable to all of us in the planning stages. Please continue to update us on your ups and downs for your own accountability and to help us get through our stalls and setbacks. As for your discouragement I think you need to look at it in a different way. Think of where you would be at this time of year without your esg procedure. After Thanksgiving and Christmas is when the most weight gain occurs usually. If you have only seen a 1 pound fluctuation without exercise then I would honestly call this a victory. This seems to be a common theme among esgers throughout the various forums— the weight loss is slow and steady not as rapid as the more invasive methods. Please continue to focus on the positives and don’t give up hope that this procedure will finally help you maintain a healthier weight. You’ve already taken the first step in committing to a your health. You just need to continue to post and not be discouraged. Best of luck in 2018!!

I've had 100+ hours of therapy at http://mocsa.org a few years ago. I was of "normal" weight then. My weight gain took off after I fell down some steps and mangled my right ankle. I had one unsuccessful surgery on it. Later, two ankle reconstruction surgeons told me there was nothing more they could do. I was sedentary and very depressed after that. It doesn't help that I have an autoimmune thyroid condition. I'm not suggesting that more therapy might not help me but a sedentary lifestyle really derailed my ability to walk or do much in the way of weight-bearing exercise. It's been 10 years since I injured my ankle. Morphine is the only thing that even gets close to taking the edge off the pain. (And I tried many other non-narcotic meds first, plus holistic treatments. My PharmD daughter finally explained to me that being dependent on a narcotic for actual pain relief is different from being addicted to a drug when no physical malady is present.) Taking 300mg of morphine per day doesn't give me a "high"; it just helps me move around without writhing in pain. I also take oxycodone for breakthrough pain. Believe me, nobody WANTS to rely on powerful meds like these. It's weird to say, but I often welcome competing sources of pain (gallbladder surgery; lipoma removal, or even my knee replacements) to help keep my brain confused about where the pain is. I expect my bariatric surgery to be no different. There's nothing that my surgeon can do to my body that can overtake the pain I live with everyday. Boo-hoo me.

Wow.... offended much? And what exactly makes YOU an expert? LMAO The whole point of my post was to encourage the original poster to seek guidance from her HEALTH team. THEY are the experts And in my reply to you I said your doc SEEMS to be more of the exception than the rule. And exactly what AUTHORITATIVE comments did I make? I didn't tell anyone to do anything... but I did say in my posts (there were 3 of them... that the OP should consult their medical team. LMAO "Yeah, I keep hearing this. From people who were so good at consuming calories they had to have weight loss surgery " I especially love this sentence... I mean... Pot Calling the Kettle Black???? LMAO BTW.... my weight gain was caused by prolonged severe sleep apnea which caused a log of health issues... I took care of the sleep apnea and had weight loss surgery so I could regain my heart health. but go on making assumptions about people you have never met before!

Ok I've been reading this thread for days. Round and round we go. This is my personal experience with carbonated beverages post sleeve. It is not to be construed as advice one way or another. Just one person's take on this subject. I drank a few sips of Dr Pepper about a week post op. Only 3 or 4 small sips because the carbonation made me feel like I'd explode. Nothing bad happened. I drank a little of it here and there, never could manage more than a few small drinks but I certainly had some any time I wanted it. Nothing bad happened. At 3 years out I will sometimes get a small Coke or whatever at 7-11 if I want one. I can drink the small size but it takes a while due to the carbonation making me feel like a big balloon. I prefer Slurpees. I can drink a small one in about 30 minutes and it satisfies any urge I have to drink Cokes. I have one or 2 each week ( ok maybe 3 sometimes) and they are delicious. Again, nothing bad happened. My sleeve works great, it sure as heck hasn't stretched, and I do not have a problem with gaining weight. If I gain a pound or 2 occasionally I just cut out the candy and slurpees for a few days and the pounds fall off. I eat what I want, drink what I want, and have done so since week 2 post op. I'm healthy, have a fully functioning sleeve, and am doing very well. No stretching of the sleeve, no uncontrollable weight gain, no adverse consequence.

How does zero calorie and zero sugar diet pop cause you to gain weight? I see Chrystal Light talked about here a lot and it has aspartame and a list of chemicals longer than diet pop. Why is that recommend over diet pop? Just because a doctor says so is not good enough for me. When I was a kid our family doctor told us we would all have heart attacks if we continued to eat eggs. Anti eggs was the fad back then and most doctors went with it. Now eggs are considered a super food. What happened? Why did doctors suddenly change? Diet pop has been out for 50 years and yet there are very few studies that actually study causation. The ones I have found show that people do not gain anymore weight by drinking diet pop. I personally have lost 70 pounds and counting drinking diet pop. None of the ingredients in diet pop has been proven to cause weight gain. Diet pop is just a carbonated version of Water and Chrystal Light.

I'm 18.5 weeks pregnant. I won't have any issues losing the pregnancy weight. I'll just low carb it again until I get the weight off. I gained a few pounds over the holidays and dropped those pounds in a little over a week just by cutting alcohol and carb consumption. As for the breakdown of weight gain with a pregnancy, this is what they've outlined for my weight gain: Maternal Fat- 7lbs Baby- 6-8lbs (average is 7.5lbs) Increases Fluid (blood volume)-2-4 ( a mother's blood volume typically doubles during pregnancy) Amniotic Fluid- 1-1.5lbs Placenta- 2lbs Breast tissue/mammary system weight increase - 1-2lbs Watch out for the ROSE procedure, it has an 85% failure rate. This is also discussed heavily on the obesityhelp.com Revision forum. ERNY (extended RNY, where they remove more intestine to start malabsorption again since intestinal adaptation has taken over at this point for you) is also an option. They will shorten your common channel by another 50-100cm. You definitely want to know before you agree to a revision if you have a pouch or stoma dilation because if you have actual mechanical failure with your RNY even a band over the pouch isn't going to do much because once the food passes through the band pouch into your RNY pouch, you will still be able to more food, and your malabsorption is gone. As for Jerusalem clinic, honestly, out of over 3 years on weight loss forums, I have never read of one patient having a RNY take down and revision to the VSG being performed there and honestly that is possibly why they are recommending the band over the bypass pouch to give you restriction again. Seriously, I can name 4 surgeons worldwide that are experienced with these surgeries, and with self-pay patients the cost just for the surgeon run upwards of 20-30k because it is such a complicated and exhausting surgery to take down an old RNY. I promise I researched revisions for months once I knew my band had to come out. The risks for complications especially leaks from scar tissue and adhesions literally quadruples with revisions vs. a virgin, unaltered stomach/intestinal tract. I had a leak with a band revision to VSG after only having the band for 8 months, and actually lost more stomach tissue because of the damage the band had done. My surgeon was experienced with revisions, and I happen to be a statistic of his that I'd like to take back. I was his first and only VSG leak so it can happen even with really experienced surgeons. I'm not slamming Jerusalem Clinic, but revisions are super tricky, complicated, and I would hate to see you fork out the money, get a surgery that is as high maintenance as the BOB procedure and then continue to struggle with your weight and be looking at or for another surgery. There have been RNY to VSG revisions performed due to reactive hypoglycemia symptoms and diagnosis after RNY, but again, it's a very complicated surgery with high risks. Just choose carefully, and continue to research your options.

Ive ALWAYS carried the majority of my weight in my thighs. I think this had a lot to do with my image issues when I was younger. I always felt fat, even when I wasn't. At one point I was so super thin, I would faint and get sick... this is NOT good. My doctor wanted my Mom to send me to a psychiatrist. It was a really weird time for me. I went to a few appointments but never went back. I was able to break out of that terrible cycle but that's when the weight gain began. Then the long story begins... Anyway once I got thinned out right now, I noticed that I was still carrying a whole heckuva lot of fat in my thighs. The terrible thing was looking at my face and upper body made me not want to continue to lose because I was (still am) boney skinny up there. It made me feel really lopsided and un attractive. So that's why I chose to have the liposuction procedure performed. I knew I couldn't keep trying to lose weight anymore. I was able to put on some very small sized pants but they would always fit really weird. Really tight in the knees and thighs but loose around the waist. My lipos were the only way I was able to fix this problem. NOT to say you will have to go through this too! I'm just sharing my personal experience. Good luck!!! Everyone loses differently. It is my hope that you will lose evenly. Merry Christmas!

How does zero calorie and zero sugar diet pop cause you to gain weight? I see Chrystal Light talked about here a lot and it has aspartame and a list of chemicals longer than diet pop. Why is that recommend over diet pop? Just because a doctor says so is not good enough for me. When I was a kid our family doctor told us we would all have heart attacks if we continued to eat eggs. Anti eggs was the fad back then and most doctors went with it. Now eggs are considered a super food. What happened? Why did doctors suddenly change? Diet pop has been out for 50 years and yet there are very few studies that actually study causation. The ones I have found show that people do not gain anymore weight by drinking diet pop. I personally have lost 70 pounds and counting drinking diet pop. None of the ingredients in diet pop has been proven to cause weight gain. Diet pop is just a carbonated version of Water and Chrystal Light. Never listen to a doctor. Just do what ever you think is right.

"Animal studies have convincingly proven that artificial sweeteners cause body weight gain. A sweet taste induces an insulin response, which causes blood sugar to be stored in tissues, but because blood sugar does not increase with artificial sweeteners, there is hypoglycemia and increased food intake." "One reference showed, in patients with Type II diabetes, that the reduction of plasma glucose and insulin levels during exercise was similar after a sucrose meal compared to an aspartame-sweetened meal.[49] These results were obtained even though the aspartame meal contained 22% less calories and 10% less carbohydrates." https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3198517/ "Taste and reward signaling in the brain is immensely complex. Research is only beginning to understand how altered brain activity with prolonged use of artificial sweeteners may impact our health long-term." https://blogs.scientificamerican.com/mind-guest-blog/tricking-taste-buds-but-not-the-brain-artificial-sweeteners-change-braine28099s-pleasure-response-to-sweet/ There is a ton of research on sweeteners, brain chemistry and satiety. The point is foods should be as natural as possible and sugar isn't a devil. Years of yo-yo dieting is the real problem and crap genetics.

Good afternoon love! Just wanted to reply to your comment and share a bit of my journey with u. I had a revision in December from a VBG(first weight loss surgery approved) in 2004 to a gastric bypass do to esophogus issues, heartburn and major weight gain. I lost 46lbs after revision. The vitamins I see you posted are great but expensive. I have blood check up every 3 months have been amazing and i take a Bariatric vitamin from amazon. 16.77 month. My health is fabulous. Look into amzon for vitamins love. It will really save you money and they work just as well. Please take your daily calcuim after revision and you will be just fine. Good luck and God Bless you

Hey Sara - my insurance covers this but I feel your pain with the infertility. I am still paying off my IVF. My husband and I struggled for a long time but we were blessed with children so keep working on it. I now have four crazy kids and a heap of credit card bills but I wouldn't change it for the world. As for the friend thing - I couldn't speak to my best friend for two weeks after she announced she was pregnant. I wanted so much to be happy for her but she told me on a day that I found out I wasn't. anyway, enough about me. keep you chin up and look into what Mrs Fuller said. Stress is a big factor in weight gain AND infertility so try and reduce yours. Best of luck to you. I'll keep you in my prayers

Hi! I am 3 years out from my lap-band surgery. About 7 months ago, I started having a bit of discomfort under my left breast when I would bend over to pick something up. When I would be sitting down, I would lean back to avoid this feeling. I had my surgery in California, but have subsequently moved to PA and am followed by a surgeon in Pittsburgh. Over the phone twice (it is a 2-hour drive), they told me that it did not sound like anything band-related, perhaps, just some inflammation. It went completely away after a couple of months. Four months ago, I went to the ER with severe abdominal pain. After x-rays and a CT scan with contrast, they diagnosed me with constipation. Okay. I took some meds and did get rid of my constipation (!), BUT since then have had chronic diarrhea (sometimes just water). In the interim, as part of the workup to determine the cause of my diarrhea, weight loss, extreme fatigue, I had a colonoscopy and EGD. Last week, the EGD showed that my band has eroded into my stomach. Now, I obviously have been in contact with my surgeon in the city, and am scheduled for an upper GI series and interview, etc. next week. On the phone, however, they tell me that none of my symptoms have to do with my band. My PCP here says that he doesn't see how it could be anything but my band. I have even found an undissolved pill in my stool. Interestingly, one of the symptoms of erosion is supposed to be weight gain because of loss of restriction, but I have lost 25 pounds in these past few months and have very little appetite and still have lots of restriction. On films, my band is pretty far into my stomach; it is not a minor erosion. I come here wondering if anyone else has experienced these types of symptoms with erosion. Because if this hypermotility is not band-associated, I'm wondering what my next step will be. Oh, in case you're wondering, I have lost 75 pounds. :confused: Thanks, Kelli

I experience similar issues. I will eat a healthy 300-350 cal breakfast about 8:30 and by 11 I feel hungry, by 11:30...very hungry. I was at 5.5 but had to get an unfill b/c my healthy protein (meats) were getting stuck and began eating the slider foods which caused me some weight gain. I am probably going to make an appt to discuss this and see what they say. Really confused. I am thinking maybe I am eating too fast at times, but it is always the chicken and turkey that gets stuck.!@#$%. Anyone else????

Janet... I had a 6 pound weight gain after surgery. Don't fret. It took me almost 6 days to see a drop on the scale at home. If your bowels are not moving, that can have an impact. Also all those fluids in the hospital really did a number on me. As soon as I was able to drink more water and get in some proper nutrition, things really improved. I was 314 day of surgery. Two days post op on hospital scale I was 320!!! Today, I am 307. Take heart, it will get better. I am living proof. I thought what the heck...only I can go for WLS and GAIN weight!!!! Hang in there. You will do fine and sorry about the bruising. I still hurt too and bending over really gives me pain. We are going to make it. I know we will. Cyber hug to you.

Here is an academic overview of the various bariatric procedures with a bit of excess 'science stuff' thrown in. No opinion. No bias. Published 2012 by the UK Royal College of Physicians. If anyone requires further clarification to the sources contained (hopefully its been copied successfully), please see the reference list at the end. This will provide you (licensing permitting) with a link to those original source documents so you can do your own further research/analysis. Any questions or queries, please do not hesitate to ask. Revs x Overview of bariatric surgery for the physician Keng Ngee Hng, Specialty registrar in gastroenterology1⇓ and Yeng S Ang, Consultant gastroenterologist and honorary lecturer2 + Author Affiliations 1Salford Royal NHS Foundation Trust 2Faculty of Medicine, University of Manchester, Oxford Road, Manchester Address for correspondence: Dr KN Hng, 4 Fern Close, Shevington, Wigan WN6 8BL. Email:keng_ngee@hotmail.com Abstract The worldwide pandemic of obesity carries alarming health and socioeconomic implications. Bariatric surgery is currently the only effective treatment for severe obesity. It is safe, with mortality comparable to that of cholecystectomy, and effective in producing substantial and sustainable weight loss, along with high rates of resolution of associated comorbidities, including type 2 diabetes. For this reason, indications for bariatric surgery are being widened. In addition to volume restriction and malabsorption, bariatric surgery brings about neurohormonal changes that affect satiety and glucose homeostasis. Increased understanding of these mechanisms will help realise therapeutic benefits by pharmacological means. Bariatric surgery improves long-term mortality but can cause long-term nutritional deficiencies. The safety of pregnancy after bariatric surgery is still being elucidated. Introduction Obesity is a worldwide pandemic,1–4 with the number of obese children and adolescents increasing alarmingly.5 This has serious health and socioeconomic implications due to the attendant increase in related comorbidities.1,2,4,6 Obesity causes type 2 diabetes, hypertension, dyslipidaemia, cardiovascular disease, obstructive sleep apnoea, obesity hypoventilation syndrome, cancer, steatohepatitis, gastro-oesophageal reflux, gallstones, pseudotumour cerebri, osteoarthritis, infertility and urinary incontinence.1–6 Severe obesity reduces life expectancy by 5–20 years.1 Diet, exercise and drug treatments for severe obesity have been disappointing.1–3,5–12 At the present time, bariatric surgery is the only treatment that reliably produces substantial and sustainable weight loss.1–7,9,13 It is indicated in people with BMI >40 kg/m2 or with BMI >35 kg/m2 in the presence of significant comorbidity.3,5,7,14 Bariatric surgery is cost effective,3,6,15 achieving weight loss, as well as improvement or resolution of associated comorbidities.1,2,5,6,9,15,16 In the past decade, the development of centres of excellence,5,6laparoscopic techniques,2,5,6 improved safety profiles2,6,9 and better documentation of clinical effectiveness2,6,15 have fuelled an increase in the number of procedures performed. Types of surgery Bariatric surgical procedures are traditionally classified as restrictive, malabsorptive or combined according to their mechanism of action. The procedures most commonly performed are laparoscopic adjustable gastric banding and roux-en-y gastric bypass.3,13 Sleeve gastrectomy is increasingly performed.2,6,7 Biliopancreatic diversion and biliopancreatic diversion with duodenal switch are much more complex and performed infrequently.2,5,17,22 Other historical procedures are no longer in common use. In addition to restriction and malabsorption, recent evidence suggests that neurohormonal changes are an important effect of bariatric surgery.2,6,7,17,18 Bariatric surgery is only part of the management of severe obesity. Careful patient selection and preparation are extremely important, as are long-term compliance with diet, nutritional supplementation and follow up.2,5,6,19 Laparoscopic adjustable gastric banding2 A purely restrictive procedure, laparoscopic adjustable gastric banding (LABG) is the least invasive procedure, is completely reversible and has the lowest mortality.19 A silicone inflatable band is placed around the stomach cardia immediately below the gastrooesophageal junction (Fig 1). This is connected to a subcutaneous port that is used for band adjustment.5,6 The band compresses the cardia to generate a sense of satiety and reduced appetite, which is thought to be mediated via vagal afferents.2 Roux-en-Y gastric bypass (RYGB) is a combined procedure that is also performed laparoscopically. A 20–30-ml gastric pouch connected to the jejunum forms the Roux limb (Fig 2). The disconnected duodenal limb is anastomosed 75–150 cm along the Roux limb, forming a Y configuration. The distal stomach, duodenum and part of the proximal jejunum are thus bypassed.5–7,20 Despite the traditional classification of the this procedure, malabsorption is not significant with the standard RYGB surgery.7 In an extended gastric bypass, the Roux limb is lengthened to increase the malabsorptive component.6,20 In sleeve gastrectomy, 60–80% of the stomach is removed along the greater curvature to leave a restricting ‘sleeve’ of stomach along the lesser curve (Fig 3).5,20,21 Originally the first step of the biliopancreatic diversion with duodenal switch (see below), sleeve gastrectomy has evolved into a staging procedure for super obese or high-risk patients.2,5–7,20 It is also increasingly used as a standalone procedure.2,6,7 Biliopancreatic diversion (BPD) and biliopancreatic diversion with duodenal switch (BPD/DS) are malabsorptive operations that result in bypass of most of the small intestine. With BPD/DS, a sleeve gastrectomy is performed, leaving the pylorus intact. The duodenum is then disconnected and the stomach anastomosed to the distal small bowel (the ‘duodenal switch’), creating a short alimentary limb. The long biliopancreatic limb is then anastomosed to the ileum 75–100 cm proximal to the ileocaecal valve, so digestion and absorption occurs only in the short common channel.5,6,20 With BPD, a partial gastrectomy leaves a 400 ml gastric pouch and the common channel is shortened to just 50 cm.5 Safety profile and complications Bariatric surgery is safe.2,5,6,9,22–24 High-volume centres of excellence deliver bariatric surgery with inhospital mortality of 0.14% and 90-day mortality of 0.35%, which is comparable to that for cholecystectomy.6 Acute complications, including haemorrhage, obstruction, anastomotic leak, wound infection, cardiac arrhythmias, pulmonary emboli, respiratory failure and rhabdomyolysis, occur in 5–10% of patients.5,6,9,10,25 Long-term complications include internal hernias, anastomotic stenoses, marginal ulceration, fistulae, diarrhoea, dumping syndrome, gallstones, emotional disorders and nutritional deficiencies.5,6,13,15,20,25–27 Patients with LAGB can experience port problems, stomal obstruction, band slippage/erosion, pouch dilation, gastro-oesophageal reflux and oesophageal dilation.5,13,19,25 Malnutrition is a concern with BPD with or without DS.1,17 Long-term risks for sleeve gastrectomy are unknown.5 The Longitudinal Assessment of Bariatric Surgery22 reported overall 30-day mortality of 0.3% for 4,610 patients having LAGB or RYGB for the first time, with 4.3% of patients having a major adverse outcome within 30 days. This was most frequent among patients having open RYGB (7.8%). A meta-analysis involving 85,048 patients reported a total 30-day mortality of 0.28% and a two-year mortality of a further 0.35%.24 The most complex malabsorptive procedures had the highest perioperative mortality at 1.11%. Mortality for gastric banding is between one in 2,000 and one in 5,700.2 Effects on weight, comorbidities and long-term mortality After RYGB, patients lose 60–70% of their excess weight over two years, and this is largely durable.1,2,6,9,15,16,28 Weight loss is dependent on long-term compliance with dietary recommendations.2,5,6 Sugary, energy-dense foods and drinks can ‘bypass the bypass’. After gastric banding, patients lose about 50% (range 39%–59%) of their excess weight at a slower rate, often continuing into the fifth year.1,2,5,6,9,19 Regular band adjustment is necessary.16 The Swedish Obese Subjects (SOS) study reported a reoperation or conversion rate of 31% for gastric banding and 17% for gastric bypass among patients followed for ≥10 years, excluding operations for postoperative complications.16 However, at the centre in Melbourne, only about 10% of patients after LAGB need some revisional procedure, including band replacement, in the following 10 years.2 Biliopancreatic diversion with or without DS produces excess weight loss of 70.1%9sleeve gastrectomy produces initial excess weight loss of 55%, but this may not be durable.2 Bariatric surgery also produces significant improvement in obesity-related comorbidities, with the most remarkable effect being resolution of type 2 diabetes (T2DM). A meta-analysis encompassing 22,094 patients reported complete remission of T2DM in 76.8% of patients,9 and a registry from the UK with data on 8,710 patients reported resolution of T2DM in 85.5% of patients.29 Major improvement often occurs within days after RYGB, before significant weight loss is achieved.5–7,17,18 After LAGB, improvement in T2DM occurs more slowly as a result of weight loss.2,7,19 Combined or malabsorptive procedures produce greater improvement than purely restrictive procedures.1,2,5,9,18 Diabetes less than three years in duration, no insulin requirement, milder obesity with BMI <40 kg/m2 and weight loss ≥10% predict complete resolution of T2DM.18,19 Bariatric surgery is now advocated by some for the treatment of T2DM in patients with BMI <35 kg/m2.4,7,30,31 Bariatic surgery effectively treats all other associated comorbidities: from steatohepatitis and pseudotumour cerebri to urinary incontinence.1–3,5,6,15 Meta-analysis showed that hyperlipidaemia improved in ≥70% of patients, hypertension resolved in 61.7% (and resolved or improved in 78.5%) and obstructive sleep apnoea resolved in 83.6%.9 At five years, the risk of cardiovascular disease had decreased by 72%.3 The incidence of cancer also reduced markedly,6,15,16 as did the risk of developing new comorbid conditions.15 Long-term efficacy is well documented.5,6,28 At follow up after 10 years, the Swedish Obese Subjects (SOS) study showed a 29% reduction in adjusted all-cause mortality, primarily because of decreases in cancer and myocardial infarction.16A retrospective cohort study of 7,925 patients after RYGB reported a 40% reduction in all-cause mortality during mean follow up of 7.1 years.23 Specific mortality decreased by 56% for coronary artery disease, by 92% for diabetes and by 60% for cancer. A large observational study, in which the vast majority of patients had undergone RYGB, reported an 89% risk reduction in five-year mortality.15 Energy homeostasis and hormonal changes Weight loss after bariatric surgery is not explained by volume restriction and malabsorption alone.17 Indeed malabsorption is estimated to account for only 5% of the weight loss following standard RYGB.17 Bariatric surgery causes significant changes in the neurohormonal profile, which contributes to sustained weight loss through changes in appetite, satiety, food preferences and eating patterns and explains the remarkable effect on T2DM.2,5–7,17,18 The hypothalamus32 Hormonal signals provide information about energy status to the hypothalamus. Adipokines are secreted by adipose tissue and enterokines by the gut. Incretins are enterokines that stimulate release of insulin after food intake.18 Two hypothalamic circuits influence food intake, and both contribute to acquisition and storage of nutrient energy. The homeostatic circuit increases appetite and locomotion in response to energy shortage. The hedonic circuit is engaged at stable weight plateaus in association with increases in body fat. It heightens finickiness to taste of food. Obese animals overeat palatable food but undereat bland foods and lose weight. In our current obesogenic environment, the hedonic circuit facilitates the seeking of energy-dense foods uncoupled from energy status. Enterokines Ghrelin,33 which is mostly synthesised in the stomach, is a potent appetite stimulator involved in hunger and meal initiation. Circulating levels are inversely proportional to BMI and respond to changes in body weight. Ghrelin enhances gut motility and speeds gastric emptying.17 It promotes lipid accumulation and weight gain, favouring glucose utilisation. It also inhibits insulin secretion and impairs glucose tolerance.18 Levels of ghrelin reported after bariatric surgery have been variable, which may be due to differences in surgical techniques and research methods.7,18Overall, the trend is for a decrease in ghrelin levels after RYGB and an increase after gastric banding.7,17 Sleeve gastrectomy, which removes most of the ghrelin-producing stomach, reduces levels of ghrelin. Peptide YY (PYY)34 is secreted postprandially by L cells in the pancreas, small intestine and colon. It suppresses appetite and promotes satiety via signalling actions in the brain. It also delays gastric emptying (the ileal brake) and enhances insulin sensitivity.7 Secretion of PYY generally corresponds to the energy ingested, although it may vary depending on the macronutrient content.17Interestingly, levels also correlate positively with exercise intensity, with resulting decreases in food intake. Glucagon-like peptide 1 (GLP-1) is co-secreted postprandially with PYY in the distal intestine.17 A powerful incretin, GLP-1 potentiates glucose-stimulated insulin secretion, enhances β-cell growth and survival, inhibits glucagon release and enhances all steps of insulin biosynthesis.7,17 It also slows gastric emptying to produce greater gastric distension and helps regulate appetite and body weight.7,17 Obese individuals have lower levels of PYY and GLP-1, and levels are decreased further in patients with diabetes.5,17,18 Two hypotheses exist to explain the hormonal and metabolic effects of the RYGB: the hindgut hypothesis the foregut exclusion theory. The hindgut hypothesis postulates that after RYGB and malabsorptive procedures, rapid nutrient delivery to the distal gut L cells and their increased exposure to incompletely digested nutrients lead to an early and exaggerated PYY and GLP-1 response, contributing to early satiety, reduced meal size and early resolution of T2DM.7,17,18 Ileal transposition studies provide strong evidence for this. Interposition of an ileal segment into the proximal gut in rodents produced exaggerated PYY, GLP-1 and enteroglucagon responses, reduced food intake, weight loss, improved insulin sensitivity and overall improved glucose homeostasis.7 The foregut exclusion theory proposes that exclusion of the duodenum and proximal jejunum after RYGB is the mechanism that mediates the effects of bariatric surgery.7,18 However, duodenal–jejunal bypass experiments in rats supporting this theory are compounded by the accompanying pyloric disruption that results in accelerated gastric emptying and rapid nutrient delivery to the hindgut.7 The endoluminal duodenal–jejunal sleeve also accelerates gastric emptying by abolishing duodenal osmoreceptor control of pyloric contraction.7 This 60 cm-long sleeve prevents nutrient contact with the duodenum and proximal jejunum, while biliary and pancreatic secretions flow outside the sleeve, delaying digestion.35 A possible mediator of the foregut exclusion theory is the gastric inhibitory polypeptide or glucose-dependent insulinotropic polypeptide (GIP), which is secreted by K cells in the duodenum in response to nutrient absorption.18,39,40 In addition to its incretin action, GIP promotes lipogenesis,41 with GIP receptor knockout mice protected against diet-induced obesity and insulin resistance,39 while antagonism of the GIP receptor improves glucose tolerance and insulin sensitivity and partially corrects pancreatic islet hypertrophy and β-cell hyperplasia.40 Levels of GIP are suppressed after malabsorptive procedures.18,41 Adipokines Adiponectin17,36,37 is synthesised primarily in adipose tissue, with levels inversely correlated with BMI. It is an important insulin sensitiser, and hypoadiponectinaemia causes insulin resistance and T2DM. Adiponectin also possesses antiatherogenic, anti-inflammatory and cardioprotective properties and may act centrally to modulate food intake and energy expenditure. Weight loss following bariatic surgery increases levels of adiponectin. Leptin38,32 is secreted by adipose tissue and regulates body weight via its action on the hypothalamus. It increases nocturnally to stimulate lipolysis but also increases postprandially to induce anorexia. In addition, leptin plays an important role in glucose homeostasis. Levels of leptin are proportional to body fat, with starvation or energy shortage activating the homeostatic mechanism in the hypothalamus to restore energy balance. However, leptin resistance develops in obesity. Weight loss from bariatic surgery reduces leptin levels.17 Many other enterokines and adipokines exist, some of which may also play a part in producing and sustaining weight loss or diabetes remission after bariatric surgery.17,18 Understanding the mechanisms of action of bariatric surgery will help realise therapeutic benefits by pharmacological means.6,7,19 Nutritional deficiencies Nutritional deficiency is common after bariatric surgery and the risk increases from LAGB through SG and RYGB to BPD with or without DS.20,26,31 The problem is heightened by the fact that micronutrient deficiencies are already highly prevalent in obese patients before surgery.21 After surgery, patients are at particular risk of deficiencies in Vitamins B1, B12, C, A and D and folic acid, as well as Iron, Calcium and Protein.20,26 Lifelong prophylactic supplementation is often necessary, and regular monitoring is essential.26 Investigation of clinical syndromes resulting from malnutrition can be challenging. Anaemia20,27 After bariatric surgery, patients are prone to iron deficiency because of intestinal bypass, pouch hypoacidity and intolerance of red meat. Obesity creates a state of chronic inflammation that can contribute to anaemia. Anaemia can also be caused by deficiencies in folate, Vitamin B12, vitamin E (haemolytic anaemia), copper (anaemia and neutropenia), Vitamin A and zinc. In refractory anaemia, gastrointestinal blood loss must be considered. Bleeding in the excluded stomach, duodenum or biliopancreatic limb is problematic as the usual endoscopic access route is no longer available. Neurological problems6,20 Neurological symptoms can result from deficiencies in thiamine, vitamin B12, niacin, vitamin E and copper or from hypocalcaemia secondary to Vitamin D deficiency. Clinical syndromes includes Wernicke's encephalopathy, peripheral neuropathy, dry beriberi, neuropsychiatric beriberi, pellagra, ataxia, spasticity, myelopathy, muscle weakness, posterior column signs and ptosis. Oedema6,20 Patients with oedema may have underlying heart failure, which can also be due to wet beriberi (thiamine deficiency) or selenium deficiency. Hypoalbuminaemia may be caused by liver cirrhosis secondary to steatohepatitis; severe protein/calorie malnutrition; kwashiorkor; and diarrhoea secondary to bacterial overgrowth, malabsorption of bile salts and niacin deficiency. Eye, skin and hair problems20 Vitamin A deficiency causes difficulties with nocturnal vision and reduced visual acuity. Vitamin E deficiency can cause retinopathy. Thiamine deficiency can present with blurred or double vision. Dry skin, pruritus and rash can be caused by deficiencies in vitamin A, niacin, riboflavin, zinc and essential fatty acids. Hair changes can be due to zinc deficiency or protein malnutrition. Pregnancy after bariatric surgery About half of patients undergoing bariatric surgery are women of childbearing age,8 which introduces specific concerns. Obesity is strongly associated with infertility8 and increases the risk of obstetric complications.8 Yet the effects of rapid weight loss and potential malnutrition in pregnant patients are of concern. Bariatric surgery improves fertility42,43 and reduces the incidence of obesity-related complications such as gestational hypertension, gestational diabetes, pre-eclampsia and foetal macrosomia when compared with obese controls. The effect on premature delivery, miscarriage, intrauterine growth retardation, low birth weight and neural tube defects and the need for caesarean section are unclear.8,43 Maternal surgical weight loss reduces the prevalence of obesity and cardiometabolic risk factors in offspring until the adolescent years.42 Pregnancy seems to have little effect on the surgically induced weight loss.8 Patients are generally advised to delay pregnancy until after the period of maximal weight loss (12–18 months).8 Extra vigilance in preconception, antenatal and obstetric care is required. Conclusion In summary, bariatric surgery is a safe and effective treatment for severe obesity and its associated comorbidities. It is particularly effective in the treatment of T2DM. Neurohormonal changes that affect appetite, satiety, glucose homeostasis and long-term energy balance contribute to its long-term efficacy. Two hypotheses exist to explain how hormonal changes produce these effects, and both may contribute. Patient adherence to postsurgical aspects of management is very important. Pregnancy after bariatric surgery brings additional considerations. Finally, the indications for bariatric surgery are being widened. Acknowledgements Dr Keng Ngee Hng is a specialty registrar in gastroenterology and has previously submitted part of this work for her Master of Science in gastroenterology (Salford University). Dr Yeng S Ang is the educational supervisor for Dr Hng and has refined the ideas, concepts and layout of the previous work. Recent updates are also included within this paper. © 2012 Royal College of Physicians

I know! I am excited to get this weight off! The start of my weight gain was fertility drugs! 45 pounds, 3 sets of drugs, and a surgery later I got pregnant. Lost weight in beginning of pregnancy and only had 3 positive pound weight gain. Over the years I had surgery for my gallbladder, appendix, stat csection, and 7 laparoscopic procedures for endometriosis. The final surgery my hysterectomy really added the weight! I just gave up! So tired of trying every diet and failing!! I exercise but I have so much belly fat from the hormones being imbalanced and scar tissue! Hoping to get this weight off and start running again! I am ready for my old self to come back!