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I waited until maybe 5-6 weeks post-op. To avoid the possibility of dumping, get an edible with a very high THC content, and only have a teeny bit. My go-to is a chocolate, but because it has so many milligrams of THC, I only need about a pinky-nail sized amount. For the brand I use, this is about 0.8 grams of sugar. Another great option is to use a tincture. They can be either alcohol-based or glycerin-based. Although, tinctures work by absorbing into the bloodstream via the mouth, and therefore work more quickly than edibles.

Why so defensive? It's a fact the better prepared you are, the odds for success will be in your favor. It's that way with anything in life. Just statung facts. But please, let your emotions rule your response. I'm no spring chicken. I'm also a WLS veteran. This isn't easy, so rushing into it and not being emotionally ready tends to spell disaster for people. I've seen it over and over and over. Hell, I've even struggled with some regain, and I'm old and researched this surgery for well over a year. I'm also a drug and alcohol counselor, so I know the difference between someone who is truly emotionally ready and someone who is not. Not saying the OP isn't, just stating the fact that when you see someone wanting to disregard protocol to get the process done faster, they may have a problem with delaying gratification, and that's a problem with this surgery. It won't choose what you put into your mouth or get your ass off the couch. You still have to diet and exercise and have discipline for the rest of your life. Many think it's magic.

Only carbonated water is good work is alcohol lol. I'm wasn't a big sofa drinker before surgery. Maybe once a week if at all but I really miss my southern sweet tea!!!!

HI all. DAy 6 and felling almost human today. A little hard with a get together and I cant eat or drink alcohol. But I got through it and am happy. Energy returning finally only a short nap today. How is everyone else feeling?

I am almost 7 weeks and was told to wait 8.. I had a Malibu rum and crystal light orange (light on the flavoring.) I had no problems and did not even get a buzz. I had in large glass. Malibu is a lower alcohol content...I had one more..drank half but felt nothing... I am an ex bartender and beer drinker...a shot now and then...I could handle my alcohol pre sleeve though. In bar business 19 years..working two jobs...loved the money! If I couldn't or can't in future then I would not drink since I hate drunk girls falling down..lol. Everyone is different so it is hard to say. I am going to miss hot summer days and cold beers but not the calories.

Has everyone completely cut out alcohol?

Q: Can I drink alcohol after surgery? A: Alcohol is not recommended after bariatric surgery. Alcohol contains calories but minimal nutrition and will work against your weight loss goal. For example, wine contains twice the calories per ounce that regular soda does. The absorption of alcohol changes with gastric bypass and gastric sleeve because an enzyme in the stomach which usually begins to digest alcohol is absent or greatly reduced. Alcohol may also be absorbed more quickly into the body after gastric bypass or gastric sleeve. The absorbed alcohol will be more potent, and studies have demonstrated that obesity surgery patients reach a higher alcohol level and maintain the higher levels for a longer period than others. In some patients, alcohol use can increase and lead to alcohol dependence. For all of these reasons, it is recommended to avoid alcohol after bariatric surgery. (American College of Surgeons, 2011) Think of alcohol as being in the same catagory as soda. It does you no good and it has the potential to cause problems. If you think having soda every so often is ok..... having alcohol every so often is ok, too. It's the same thing. If you wouldn't do one...don't do the other.

@@anthonyb It also depends on what you are eating. If you go from 1200 low carb calories to 1600-1800 carby calories, you are going to gain weight, just because your liver is going to be larger. Are you drinking alcohol? Did you exercise and stop? Are you going through a stressful time in your life? There are so many factors to weight gain.

I appreciate your concern but I’ve actually be doing really well food wise and am just trying to make wise decisions for Memorial Day Weekend and such. I already gave up alcohol for lent just to tack on another reason why I can’t drink it lol!! Right now all I drink is water with the occasional diet snapple. If you have any preferred drinks please share!!

I know why I over eat... I LOVE food, I love cooking food, I love eating food and I love sharing food. I too watch The Biggest Looser and love the show, but I'm sorry, when they do that "root problem" thing, I just laugh. It has nothing to do with my weight issues. I have people in my life that have suffered unbelievable pain and sorrow and nope they're not fat, nor alcoholics or drug adicts, and I have friends that have the greatest life in the world and they're fat, so, to me I believe it's about will power and the ability to change your eating habits and no longer indulge in wonderful tasting fattening foods. I frankly LOVE food, I love butter, whipping cream, cream cheese, and that will never change. I need to be held accountable for my own weight gain and poor eating habits, it has nothing to do with my life issues. There is a member on here that was on "The Biggest Looser" and the world watched her loose all her weight, but soon as her life and reality started again, she began gaining, so was recently sleeved. I haven't read anythig from her lately, so I hope this has helped her.

Wow, 1 month. I like your 3 month plan better haha. I barely hit my Fluid goals without adding in alcohol, which will dehydrate you. Everything going on in my body, the last thing I want is alcohol. Maybe occasionally down the road but I cannot imagine it now. If you do drink, make sure you have extra fluids that day and don't forget 1 drink is going to hit you a lot harder than it used to.

LOL! You guys are too funny! I totally agree I would be pissed if my hubby had brought wings into the house also! My honey keeps his "treats" in his man cave away from my eyes....even before I was banded when I was doing weight watchers I ask him to keep his oreos and what not in his man cave! I don't think that's cruel...it's being supportive. If he was an alcoholic and trying to get clean I wouldn't leave bottles of wine in the fridge or drink it right in front of him...I would want to be supportive in any way I could be! So why wouldn't it be the same for us when we are trying to loose weight and get healthy. I don't keep any kind of junk food in my house...I'm sure my 9 year old would love to have chips and ice cream and what not at her disposal but does she really need all that? The way I look at it is she's not deprived I'm trying to teach her how to eat healthy so that she doesn't end up morbidly obese like her mom! I wouldn't wish that on her and she has my genes so why not try to keep her as healthy as possible. That's not to say she doesn't have junk food at times...she had plenty of candy for valentines day that she ate....but as far as what's in the kitchen and in the cupboards it's all healthy! And her and my honey eat the same meals as I do for the most part! I just got off liquids and I know it's torcher....we did eat soups as a family then too...it didn't kill em and they ate a good dinner! For the OP I'm glad your hubby was understanding after you explained it to him!

:faint: She didn't mean get hammered, and she wasn't advocating it; she was just stating that medically, it wouldn't hurt anything. I think my story speaks for itself that I am super serious about my weight loss journey. My partner has busted his behind to earn this master's degree, and if he wants me take a sip or two of some no-carb libation while we are in 5 different countries in southeast Asia, I think I can do that without disrupting my journey in any way. Absolutely! Do your thing! I just can't imagine being given the nod for alcohol a month out. My stomach wasn't even fully healed yet.

Hello Bariatric Buddies (corny right? lol) I thought I'd come on here and share my experience so far for those who may be thinking about weight loss surgery OR are scheduled to undergo surgery soon. I started my bariatric surgery journey May 4th 2021 after YEARS of wanting to do it but not having the courage to start. At that point i was 298LBS. At my heaviest i was 305LBS. What prompted me to just go for it and conquer my fears was just wanting to be healthy again. I was tired of making excuses and as sad as it sounds i was tired of looking in the mirror every day staring at myself morphing into this person i no longer wanted to be. Fortunately for me, i didn't have any MAJOR health issues, however i did/do suffer from PCOS (Polycystic ovarian syndrome). For anyone who knows the struggles of PCOS you know trying fad diets and exercising isn't really helpful when trying to lose weight when your hormones are so imbalanced. Any who, going forward - i contacted my local bariatric surgery center and set up my initial consult. Since we're still being affected by covid, majority of my appointments were via video. My first consult they went over my eligibility requirements, health history and goals. After speaking with the nurse navigator they then scheduled my next visit with the Surgeon who would then change my life forever. So, two weeks later, i meet my surgeon VIA zoom (and let me say, i love that she was blunt, super honest and made sure my goals and perception of the surgery was realistic), she told me about herself, she asked me a few questions about my life, health history in depth, and she then went over my surgery options and what she felt would be my best choice (Gastric Bypass RNY). We ended the appointment on a good note. At that point i was feeling good, motivated and just proud of myself, like - GOSH, I'M FINALLY DOING THIS! At this point in the process, i have scheduled an appointment to get an EKG, chest X-RAY, cardiology, pulmonary, and a behavioral specialist. Over the course of 4 months i would complete each appointment and the specialists would send over their impressions over to the surgeon. September 3rd. I had my pre op class (with a dietitian). I signed a bunch of papers stating that i would not consume alcohol or use tobacco. I watched a video and then the dietitian stated that starting September 9th - until September 19th i will need to be on a full liquid pre op diet - at that point in the liquid diet you are not allowed to take any vitamin supplements, and or specific medications (they would go over that with you). September 9th came around and i started my three protein shakes a day, with drinking 64OZ of water until September 19th as advised. Let me tell you, that was the single most hardest thing that i have EVER done, but in the end i was so proud of myself. September 20th at 10:00AM i had to drink 10OZ of Magnesium Citrate to bowel cleanse in preparation for surgery the next morning. I spent all day in the bathroom. Around 1:30PM i received a call from the hospital letting me know what time i needed to be at the hospital for surgery the next day (9/21/21) which ended up being 7AM. I had so much trouble falling asleep that night as i was so excited yet SO nervous! Surgery day rolls around and i am up getting ready. We (my boyfriend and i) then make our way to the hospital, check in, and head to my pre op room to be prepped. They took my temperature, and my weight. When i started, i was 298 - the day of surgery i was 282LBS! At 9:40AM i went in for surgery and was in the OR for about 4HOURS. I spent about an hour and a half in recovery where they gave me 1OZ water every half hour, that would continue as i was transported to my room that i would stay for the next 24HOURS. My hospital stay wasn't bad, and my nurses/doctors were super attentive, supportive and courteous! They came in almost every hour to check my temperature, blood pressure, and incisions. I went home 9/22/21 at 9:40AM. 1st day home was challenging. I was in so much pain and discomfort. That quickly subsided as the days passed. But in those days, i attempted to drink water and protein and move around as much as possible because walking truly helps with the pain. Here i am 9 days post op and i am not at 100% yet but i am improving i still feel slight pain only where i have internal sutures, and i am gassy (like burping and stomach feeling bloated) - for that i use GAS-X - it's amazing! I currently weigh 273LBS which makes a total of 25LBS lost and 9LBS lost since surgery. 6 Day's post op i was back at work (I KNOW I KNOW I AM CRAZY - BUT I WORK IN AN OFFICE AT MY DESK MAJORITY OF THE DAY SO I AM OKAY).. Hopefully this helps! & if anyone has any questions, please feel free to ask :)

You have to make a permanent change to your mindset or you will regain. I am focused on my health period. Everything I think and do supports that. I changed my mind, the sleeve was a tool. I am 2.5 years out and down 118 lbs. permanently. My hobbies are cooking healthy foods and being active in dozens of ways. I don't have any unhealthy habits as I have determined to eliminate each one step by step. I got honest with myself about what made me fat to begin with and fierce about changing mindset. I do not self indulge on food, alcohol or negativity. I am a different person. Tackling the mental/emotional is the real key to success but without the sleeve as my tool I would have lost hope and incentive. Sent from my iPad using the BariatricPal App

Surgery is about 3 weeks out. I have to do the liver reduction pre op diet and I know about the post op diet stages. Of course all WLS materials tell you " no alcohol " even later on. I know there's calories but at this stage of my life I really enjoy a glass or 2 of red wine on the weekend nights. Is this gonna be a problem long term?

The day after Halloween...and I feel like I have a hang over! It's very odd because I have not touched any candy, I did not drink any alcohol, but today I'm feeling like I was up all night drinking and partying. Today I did allow myself one almond cookie, this lovely lady in our education department brought in from the bakery on her lunch hour. (I know everyone wants to beat her over the head!) I have to tell you though I could only eat about 3/4 of it and the smell of the rest of them was actually making me feel sick. I had to move them all into the kitchen away from my desk. I'm the "festive" gal around these parts, so everyone brings things and brings them to me, because I am the self appointed party planner on top of my actual "work" title I'm glad to see people bond together though, so I'm happy to be the office cheer leader, it makes for a nice mix of people working together and getting so much more done then working against each other. There is a method to my madness but don't let them know. I can't wait to go home today and just get into my PJ's and crawl under my covers and turn on the idiot box as my Mother used to call it, and do NOTHING. I took a couple of Advil and might need a couple more to get rid of this brewing migraine...been drinking lots of water, and just trying not to get into full blown black out the world migraine. I love how the band really helps us to avoid these testing times like Halloween. I LOVE the spirit of the holiday, and this year I really have no desire for candy or cake and if I want to have something I can and do and it's very small just a taste and I'm satisfied. Maybe next year I'll have to have a real bitchin party so if I have to feel hung over it will be well worth it after a rocking party!!! At least my body could ache from dancing all night instead of just the miserable weather Hope you all had a good one...I'm off to PJ land and beddybye. Have an awesome weekend all!!!

Lol, you forgot beer or alcohol lol Sent from my iPhone using the BariatricPal App

How sweet you all are to worry about me!!! I am home---we actually come in late last night, but had a Superbowl party planned, and I was running around like a chicken with my head cut off trying to get ready. Done and behind me, a good time was had by all. We used to always go to some friends house, but there was always tons of alcohol around---and now that we have the next generation running around, we decided to have our own good time. We had all the kids, and their kids, and some friends in---they had some beer, the rest of us drank iced tea, and soda. We enjoyed it a lot---I am glad however to be home --- sitting!!! Darcy---I logged a total of 27 miles in January. Mary--I am so glad you took your little guy to the Dr.---hope he is on the mend! Volunteering will enrich you in so many ways---I'm proud of you! Chris---beautiful picture!!! Well sorry all you Bears fans----was kind of a ho-hum game for us, we had no real strong feelings one way or another. In fact, until I read about all of you wanting the Bears to win, I was very vociferously going for the Colts. Remember my niece that was such a snot over the pictures at Christmas? She is a huge Bears fan, and in one day inundated my email box with 87 emails all saying things about the Bears, and dogging DH's team (Broncos---we lived in Denver for years!!). I eventually blocked her!!! So I just had to hope they didn't---then you all wanted them to win---so I just refused to take sides!!! I just watched football to get to the commercials! We had quite the trip to Denver---over 350 miles of snowpacked, icy roads. We got there and spent the remainder of the day holed up in the hospital, with my SIL. When we left, having to take another niece to get her son, we left in a huge blizzard...in the middle of rush hour...in down town Denver! Between the roads, the traffic, the accidents causing multiple detours....to get home took us over 3 hours! Our windshield wipers froze to the windshield! Then we woke up to horrid noise on Friday----70 mph wind gusts---with a sustained wind speed of 50-55 mph. Blowing snow so thick, you could not see. We finally made it to the hospital, to bring my SIL home...and had a big dinner with the rest of the family, played some Mexican Train dominos....and had a good time. Our drive home, was better, still snow packed on the mountain passes...but nothing like the trip up. Wolfcreek, one of the mountain passes we have to go over, has over 110 inches last I heard----they have the road side reflectors stacked 2 high---and they were buried in the snow........with the fresh snow on the road, it looked like you were in a tunnel---wild looking, I videotaped it all the way over! We did really well, only kicked our 4WD drive in a couple of times the whole weekend---glad I got new tires tho!!! Mandy--glad the foot is on the mend, hope your fill works wonders. I have 1/2 a pound to go---and I am no longer obese. Now after the chips and queso---it may be more!!! Once I finally get to the "overweight" category, then I only have a few pounds to go until Onederland---then several more and I will make the 100 pounds lost. You would think with all these cool goals, I would have lots of motivation---but it is hard to stay focused. Sherry---I'd choose most things over the aquarium cleaning---every now and then DH and I will think about an aquarium, and that holds us back---we are so lazy! Cassie---I am glad you feel better---not sure if alcohol will do that or not, but glad you feel better. Dianne--you sound much better---glad to see you feeling better, and happier, family health issues, can get you down, I understand. Anne---good luck in the orientation---poor you! Beannie---sounds like a bunch of us are night owls!!! I wish DH went in to work later----his 5 AM kills me!!! Cindy---how was the hot date with DH? Betty--what goodies do you have for the superbowl party? My youngest DD makes a Queso dip, mmmmmm. The oldest DD, does hot wings, but they are HOT! So this year she made some with a honey BBQ for me and the kids!!! I did pulled pork bbq sandwiches, and we had lots of chips, and dips, and sweets of course....there was tons of food, and I sent leftovers with everyone---they were not allowed to leave without some! Sorry if I missed some of you---my brain is fried! Well it is late, I am tired. It was a quick trip to and from Denver...but worth it. Tomorrow I have to go "Discuss" a few things with a local guy who ran through my FIL's field fence. He just drove off, but a neighbor got his license, and "name" when he was trying to unstick his truck. Well the name was a fake...but we tracked him down. He called later and cussed my 80 year old FIL up one side and down the other---finally agreeing to come and fix the fence today. Well guess who never showed up. So tomorrow, I intend on going to the Sheriff's office, then to visit with him. JERK!!! He told the neighbor his name was Randy Pierce...and he worked for Aztec Welding. In reality his name is Jan (pronounced Yon) Pearson, and he owns a local business called New Mexico Metal Art. I want a deputy present when I inform him, that if he EVER calls and curses at these old people again, he will face assault charges! Wish me luck....DH wants me to wait and let him handle it on Wed. when he has the afternoon off---but it needs done now. Off to bed! Missed you guys! Kat

Hi Cass, I know I don't go regularly like I used to and there were a few days since surgery that I felt really bloated. I tried the Ex-lax but even with that not much happened lol. Think about the food you ate...was it out of the norm, really salty? the alcohol probably didn't help matters if you haven't drank in a while not because of the alcohol in it but the sugars. I'm glad you're feeling better though. Just got done cleaning house even though there is more to do I'm retired for the day. Nothing like working hard to clean it only to have two guys in your life flop things down where they don't belong so I'm giving up. Of course I say this but knowing my BIL and SIL are coming over and my SIL and I will be stuck in the office while the guys watch the football game...means I have to YET AGAIN clean the futon of crap that's not mine. It seems to be the local drop off for the biggest guy in the house. Hmmm it might end up on his side of the bed to do something with....then again why bother cause I'll end up having to clean it GRRRRRRRRRR. I think this is one of the only things that gets my goat! I have to BEG for help and even then I have to remind the guys they said they'd help. unreal...oh well....spose I'll take a breather and get my ars cleaning this crap up yet again. Ever get the feeling that's all you do on weekends is clean? So work 50-55 hours a week and come home and do more....Can ya tell I'm not peaceful today lol. I'll get there....just needed to vent a little first lol. I know I'm not the only one that goes through this but I wanted to let you gals know it's not just you either lol. Hmmm looking over...seeing the fish tank is getting cleaned...hmmmm...guess I'll stop complaining about the futon huh? lmao Rather pick up coats, sweatshirts, tools, books, magazines, socks from the futon than pickup fish poop lmao (God works in mysterious ways to remind us to shut up huh? hahaha)

My surgery is July 1st. I am really excited. My biggest concern is the recovery time for return to work. I am trying to prep my body for surgery by eating healthy, trying to exercise, and cutting out alcohol. I have told many of my friends about my surgery. Everyone has been supportive so far. They just want me to be healthy.

Alcohol prep pads worked well for me Sent from my SM-A102U using BariatricPal mobile app

The decision whether to get weight loss surgery is one of the most important ones you will ever make. If it is right for you, bariatric surgery can give you a new lease on life as you lose weight and feel great. If you are not ready, weight loss surgery can be a painful experience that does not solve your weight problems. If you are on the fence about it, take your time coming to a decision. Even if you are theoretically eligible for it, you might have a funny feeling about it still. Here are five signs that might be saying that you are not yet ready for WLS. 1. You want to know how soon you can have … Whatever “…” may be, if you are counting down the days until you can have it after your surgery, you might be missing the point. This is a lifetime commitment. It is not a 30-day period of abstinence from alcohol or from pizza. If your mindset is that this is a short-term race to goal weight, bariatric surgery might land you where other diets have: at goal weight and then back to starting weight, plus a few pounds. 2. You’re looking for any excuse to be found ineligible. You may technically qualify for weight loss surgery based on your BMI and any obesity-related health conditions you may have, but are you ready? You might not be if you are grasping at straws to come with reasons you that you “should not” have surgery. For example, you practically ask a doctor to disqualify you because your great-grandfather (who was a smoker) died of a heart attack at age 92 and therefore you worry your heart is not strong enough to withstand surgery. (Note: it is absolutely the right thing to do to explore all of your health history to be sure that the surgery is a relatively safe option for you. Just distinguish between real and imaginary reasons). 3. You are seeking fourth, fifth, and sixth-second opinions. Let’s say your primary care doctor recommends that you have the surgery, and you found a surgeon who gave you the go-ahead. It’s one thing to ask another expert for a second opinion, just to be sure that you are making the right choice. It is quite another to ask several more experts for their opinions, hoping that one of them will advise against surgery. If that is the case, it might be a sign that you are not ready to commit to weight loss surgery and the lifestyle changes that are part of that commitment. 4. You are not sure how it would be different than dieting. Bariatric surgery is worlds away from dieting. If you are thinking of bariatric surgery as a new diet that you will follow until you reach goal weight, you probably will not be prepared to sustain your new eating habits for life, and the weight will come back, just like it may have after countless diets. If you cannot explain to yourself why this is different than previous diet attempts, you might end up with the same results. 5. Your SO is doing more research than you. It seems like every day, your significant other or your mom or your sister is telling you factoids about surgery that they discovered while researching online or talking to people. In the meantime, you have not seemed to be able to find the time to look things up. The fact may be that you are just not that engaged, which may be a sign that, deep down, you are not ready to take the plunge.

Obesity Surgery Springer Preventing Wernicke Encephalopathy After Bariatric Surgery Erik Oudman, Jan W. Wijnia, [...], and Albert Postma Additional article information Abstract Half a million bariatric procedures are performed annually worldwide. Our aim was to review the signs and symptoms of Wernicke’s encephalopathy (WE) after bariatric surgery. We included 118 WE cases. Descriptions involved gastric bypass (52%), but also newer procedures like the gastric sleeve. Bariatric WE patients were younger (median = 33 years) than those in a recent meta-analysis of medical procedures (mean = 39.5 years), and often presented with vomiting (87.3%), ataxia (84.7%), altered mental status (76.3%), and eye movement disorder (73.7%). Younger age seemed to protect against mental alterations and higher BMI against eye movement disorders. The WE treatment was often insufficient, specifically ignoring low parenteral thiamine levels (77.2%). In case of suspicion, thiamine levels should be tested and treated adequately with parenteral thiamine supplementation. Keywords: Clinical nutrition, Dietary, Bariatric, Gastric, Obesity, Wernicke’s encephalopathy, Thiamine Introduction The prevalence of morbid obesity has risen to global epidemic proportions and bariatric surgery has been shown to be the most effective treatment to achieve substantial and long-lasting weight loss for morbid obesity [1–3]. In the past decades, the number of bariatric procedures performed has increased exponentially. Currently, laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy are the most commonly performed bariatric procedures with more than 500,000 interventions worldwide per year [4–6]. Wernicke’s encephalopathy (WE) is an acute neuropsychiatric syndrome resulting from malnutrition and a possible adverse complication from bariatric operations. WE is characterized by the classic triad of ataxia, eye movement disorders, and mental status change. The prevalence rate of WE is 0.6–2% of the population, but the condition is often only discovered at autopsy [7]. Current guidelines for bariatric surgery suggest preventive thiamine suppletion (12 mg) in multivitamin treatment for all patients undergoing surgery, but higher doses for patients with suspicion for deficiency [8]. The aim of this paper is to review the clinical characteristics of WE after bariatric surgery, also referred to as “bariatric beriberi” [9] and to raise the clinician’s index of suspicion about this neuropsychiatric diagnosis and its preventability. Methods We searched MEDLINE, EMBASE, and Google Scholar, using MeSH terms (WE, Korsakoff syndrome, beriberi, restrictive weight loss surgery, gastrectomy). There were no language restrictions. Studies published from 1985 to 2017 on bariatric surgery with a diagnosis of WE were included. We reviewed the title and abstract of these articles, and indexed the data for year of publication, age, sex, BMI, onset duration and progression of symptoms, radiographic findings, treatment, and follow-up. All included studies were either case reports or case series, since information on the course of illness and symptomatology was often lacking in all group studies. The maximum number of represented case descriptions in one study was five [10]. One study reviewed four cases [11], three studies reviewed three cases [12–14], and eight cases reviewed two cases [15–23]. Cases were excluded if too little information was available to confirm a diagnosis of WE or no clinical characteristics regarding the patient or course of illness were available. Since the collected data is not a random sample of cases, and not likely to be normally distributed, nonparametric statistical procedures were applied (Mann-Whitney U test for comparison of two independent means, chi-square test for multiple means). The recorded data are either number of patients (percentage) or median (range) as appropriate. Results General Overview We identified 118 case descriptions in the published literature [9–101]. The most common bariatric procedure was Roux-en-Y gastric bypass [9–13, 15–18, 24–63], followed by sleeve gastrectomy [19, 64–85] (see Fig. 1 for an overview on the characteristics of the identified bariatric cases that subsequently developed WE). [https://www] Fig. 1 Bariatric procedure case descriptions (n = 118) leading to Wernicke’s encephalopathy (left), gender and age distribution of case descriptions on Wernicke’s encephalopathy after bariatric surgery (right, n = 113) ... Importantly, new cases of WE have continuously been published since the early beginning of weight loss surgery, and the total number of reported bariatric WE cases is growing per 2-year period (Fig. 2), suggesting that it is still relevant to review this differential diagnosis. Also, the total number of bariatric interventions (NHDS and NSAS databases (1993–2006) [102] and ASMBS database (2011–2016) [103]) has been rising each year [5], resulting in a relative decrease of WE cases per intervention (Fig. ​(Fig.22). [https://www] Fig. 2 Reported bariatric WE cases by 2-year period (left) and relative reported WE cases by 2-year period compared to general reference information from NHDS and NSAS databases (1993–2006) [23] and ASMBS (2011–2016) [102]. The red dotted line ... Descriptions of sleeve gastrectomy [19, 64–85] had a more recent publishing date (median 2014) than papers on Roux-en-Y gastric bypass [9–13, 15–18, 24–63] (median 2006) (U (85) = 301.5, p  [https://www] Fig. 3 Months after bariatric procedure, Wernicke’s encephalopathy was diagnosed per surgical procedure (n = 115) Vomiting We further analyzed the symptomatology in all case descriptions. Vomiting was the most frequently described presenting symptom (103 cases, 87.3%) and could be seen as the most relevant precursor of WE. From the literature, it is known that vomiting can also be a major complication in bariatric surgery and is one of the most frequent causes of postoperative readmissions [104]. Severe vomiting is not a normal situation after bariatric surgery and therefore further investigation in cases with frequent vomiting is indicated. In the present sample, non-vomiting cases were distributed throughout all onsets post-surgery, but only 5 out of 15 case descriptions were after the first year, suggesting that other causes than vomiting are likely to cause WE later post-surgery. Alcohol abuse (2 cases), a malabsorptive bariatric procedure (2 cases), and a new operation for hernia (1 case) could explain the late onset in non-vomiting WE presentations, suggesting other factors that negatively affected vitamin B1 storage. Importantly, severe infections, such as postoperative intra-abdominal abscesses leading to thiamine deficiency [78], are also a common presenting feature of WE and are likely to relate to an adverse outcome of WE [105]. Wernicke Encephalopathy: Presenting Characteristics The most profound characteristic of WE in the reviewed case descriptions was ataxia (84.7%, 100 cases), presenting itself as gait abnormalities up to the full inability to walk or move. The second characteristic was an altered mental status (76.3%, 90 cases), presenting itself as delirium, confusion, and problems in alertness or cognition. The third characteristic was eye movement disorders (73.7%, 87 cases), such as nystagmus and ophthalmoplegia, resulting from extraocular muscle weakness. The full triad was present in 54.2% (64 cases), a percentage much higher than the originally reported 16% of patients that present themselves with the full triad in literature in post-mortem case descriptions of WE in alcoholics [105]. Post hoc analysis in the reviewed sample shows that patients presenting themselves with mental status change were older (median 36 years) than patients without mental status change (median 25.5 years) (U (66) = 262, p Moreover, patients with eye movement disorders had a lower BMI (median 45.6 kg/m2) than patients without eye movement disorders (median 52.1 kg/m2), suggesting that a higher BMI can protect against this symptom of WE in bariatric cases. Male patients that did not present themselves with eye movement disorders had a later onset of symptoms (median 24.0) than male patients that did have eye movement disorders (median 3.5) (U (33) = 49, p  Imaging CT scans of the brain did not reveal any significant radiological finding in all cases undergoing this procedure (13 cases), suggesting that CT imaging is not the most suitable imaging technique to detect WE. In 65.6% of the case descriptions where an MRI was performed (40 cases) the procedure revealed radiological alterations. This percentage is somewhat higher than the reported sensitivity of 53% in an earlier study on WE [106]. Of interest, positive MRI results were more frequently associated with mental status change (χ2 (1) = 3.9, p  Treatment: Too Little Too Late According to the European Federation of Neurological Societies and the Royal College of Physicians, 500 mg of parenteral thiamine should be given three times daily until symptoms of acute WE resolute. The treatment is lifesaving and has the potential to reverse this acute neuropsychiatric syndrome [107]. A total of 57 (47.5%) case descriptions were reported in detail on the treatment of WE symptoms. Suboptimal treatment, with relatively low doses of parenteral thiamine (Importantly, a progressive clinical course was visible in 31.6% of the patients (37 cases), resulting in post-acute deterioration of neuropsychiatric and neurological symptoms. This suggests that the diagnosis was easily missed, resulting in a lower likelihood of full recovery. Moreover, the detrimental effect of not treating WE promptly is visible in Fig. 4 showing that many of the patients who developed more than one acute symptom later progressed into chronic Korsakoff’s syndrome. This neuropsychiatric disorder is characterized by severe amnesia, executive problems, and confabulations, leading to lifelong impairment [108]. Patients that developed Korsakoff’s syndrome had significantly more acute symptoms (median 3 symptoms) than patients that did not develop Korsakoff’s syndrome (median 2 symptoms) (U (99) = 703.5, p  [https://www] Fig. 4 Long-term cognitive outcome related to number of acute symptoms (left), MRI outcome (middle, n = 55), and too low levels of thiamine treatment (right, n = 52) Although this finding was not significant, in the group that presented themselves with acute MRI abnormalities, more cases later developed Korsakoff’s syndrome (Fig. ​(Fig.4).4). Also, too low dose of a dose of thiamine suppletion therapy resulted in more cases of KS despite the lack of significance. Non-compliance Of interest, in 10.3% of the case descriptions (12 cases), non-compliance to the medication and follow-up medical regimen was reported. A lack of insight into a given situation is a relatively common sign of the acute and chronic phase of WE [105]. The patients did not follow their follow-up, did not take prescribed drugs, or discharged themselves from the hospital against advice, leading to adverse outcomes. Because of the severity of the syndrome, this aspect requires specific attention in the treatment of WE patients, and at risk bariatric patients. Discussion Persistent vomiting is a common symptom suggesting a complication after bariatric surgery [109]. Nausea, vomiting, and a loss of appetite are also common, non-specific symptoms of thiamine deficiency [8]. Ultimately, vomiting and a loss of appetite are also a preventable cause of thiamine deficiency [110], leading to Wernicke’s encephalopathy (WE) in the majority of bariatric case reports. Adequate, timely, prophylactic, and substantial thiamine treatment in all patients undergoing bariatric surgery is required to prevent the development of WE, which is a rare but severe complication. The present review highlights that current treatment was neither prophylactic, adequate, timely, nor substantial in the majority of cases, leading to worsening of WE symptoms, the development of additional WE symptoms, and ultimately chronic Korsakoff’s syndrome. One of the most remarkable findings in the present review is that the initial symptoms of WE are often not recognized as such, leading to a prolonged state of emergent WE. In 31.6% of the cases, the initial symptoms progressed into more severe symptoms, ultimately leading to chronic Korsakoff’s syndrome. Prompt treatment of the first symptoms suggestive of WE with high doses of parenteral thiamine replacement therapy is necessary to prevent further damage [110]. According to the European Federation of Neurological Societies and the Royal College of Physicians, 500 mg of parenteral thiamine should be given three times daily until symptoms of acute WE resolve [107]. Interestingly, guidelines for treating WE suggest that patients suspected of WE should already be treated as such [107, 111]. Additionally, prophylaxis of WE following early signs and symptoms is only achieved by use of parenteral vitamin supplements, since oral supplements are not absorbed in significant amounts [111]. Moreover, in bariatric surgery, it is always relevant to give prophylactic vitamin therapy, according to international guidelines, to prevent patients from WE. Of interest, newer methods for bariatric surgery such as sleeve gastrectomy and intragastric ballooning still can lead to WE, despite their relative benefits for the patient. Recently, Armstrong–Javors (2016) pointed out that new techniques lead to the primary risk factor of WE, namely vomiting, despite a theoretical advantage by reducing the stomach volume without bypassing the duodenum [112]. Suspicion for WE should therefore be equally high in more traditional surgical procedures and newer procedures. Also, the risk of developing WE due to vitamin B1 deficiency is not restricted to the first half year after surgery but appears to be lifelong, given other factors such as new infections, insufficient meals, or alcohol consumption [110, 113, 114]. Preventive education on the necessity of sufficient vitamin intake should be given before bariatric surgery is performed and is relevant in long-term follow-up. Bariatric patients in their teens or twenties are likely to be more protected for mental status change in the course of WE than patients in their thirties or older, as reflected in a younger age of non-mental status change patients. This finding is in line with earlier reports showing that age is the strongest predictor for postoperative delirium [115, 116]. Importantly, pediatric patients and young adults undergoing bariatric surgery therefore require more attention for sensorimotor problems, such as ataxia and eye movement disorders, besides prophylactic parenteral thiamine treatment. In this specific group, more attention to lifestyle training should be an essential element of treatment, since non-compliance is relatively higher [50]. Relatively more cognitive reserve in combination with non-compliance can leave symptoms of WE unnoticed for a longer period. Although eye movement disorders such as nystagmus and ophthalmoplegia were much more common in bariatric cases than those in the general WE population [113], a higher preoperational BMI was predictive for fewer eye movement disorders. Additionally, male subjects with longer post-bariatric onsets often had no eye movement disorders as a presenting characteristic of WE. It is likely that eye movement disorders represent the most severe form of thiamine deficiency, since it is also the least common phenomenon of the WE triad. Moreover, females are at greater risk for full thiamine depletion than males [8]. A possible mechanism of action explaining the protective effect of higher weight is a greater storing reserve of thiamine in severely obese patients in comparison with less severely obese patients. This mechanism of action has been referred to as “preferential intracellular thiamine recycling” [116], leading to relatively less thiamine depletion in patients with higher body weight. Often, cases with WE following anorexia nervosa present themselves first with eye movement disorders [117], suggesting that this symptom is likely to be the result of full thiamine depletion. This suggests that both patients with lower body weight, and female patients are at greater risk for developing WE, and should guide clinicians in preventive thiamine therapy [1–4, 118]. Radiologic imaging can be employed to support the diagnosis of WE, but is not always sensitive to WE symptomatology. Often, hyperintensities were visible in the thalamic region, the mammillary bodies, and the region around the third and fourth ventricle, in line with previous research on WE [7]. Our results show that MRI alterations are frequently associated with mental status change, but not the motoric aspects of WE. This finding is relevant, because it suggests that specifically in bariatric patients with motoric problems, such as ataxia or eye movement disorders, WE should be treated despite the outcome of an MRI. Non-compliance is common in WE patients following bariatric surgery (10.3%) and could be viewed as a more discrete symptom of the disorder. Patients with WE lack insight into their situation, due to the severity of the neurological problems [108, 110]. Education on the direct adverse consequences of malnourishment should be incorporated into the provision of information before surgery. After surgery, more automated checks on vomiting are relevant. A limitation of the present review is that we only reviewed case descriptions. Therefore, predictive information regarding prevalence rates and incidence rates is limited. Despite this limitation, the level of detail in the reviewed case studies leads to new insights into WE following bariatric surgery. Recently published studies on treatment perspectives of WE in general and psychiatric hospitals are alarming: European as well as American studies demonstrated that most patients did not receive thiamine at all or only received it orally in low doses [119, 120]. Both types of treatment lead to unnecessary cases of chronic Korsakoff’s syndrome characterized by severe amnesia, executive problems, and confabulations, leading to lifelong impairment [108]. It is therefore important to highlight the clinical signs of symptoms in this specific condition. In conclusion, there is a growing number of bariatric patients worldwide. Malnourishment-related WE is a rare but severe and preventable consequence of bariatric surgery that warrants attention given its rapid onset and detrimental course. All bariatric procedures can lead to deficiencies and therefore to WE. WE can be fully prevented by supplying prophylactic thiamine given either parenterally in vomiting patients or orally in non-vomiting patients. Mental confusion, eye movement disorders, and ataxia are often missed as crucial symptoms of WE. After the initial onset of symptoms, rapid treatment with high doses of thiamine is still a life-saving measure, directly ameliorating the core symptoms of WE. The large distribution of WE onsets suggests that bariatric patients remain more vulnerable to vitamin B1 deficiency for life, and therefore require lifelong routine follow-up on their B1 status. Acknowledgements We thank Topcare for supporting excellence of long-term care. We also thank Misha Oey for her advice, and textual suggestions. Compliance with Ethical Standards This review was conducted in compliance with the ethical standards. Conflict of Interest The authors declare that they have no conflict of interest. Ethical Approval Statement This article does not contain any studies with human participants or animals performed by the authors. Informed Consent Statement Informed Consent statement does not apply. Article information Obes Surg. 2018; 28(7): 2060–2068. Published online 2018 Apr 24. doi: 10.1007/s11695-018-3262-4 PMCID: PMC6018594 PMID: 29693218 Erik Oudman,[https://www]1,2 Jan W. Wijnia,1,2 Mirjam van Dam,1,2 Laser Ulas Biter,3 and Albert Postma1,2 1Experimental Psychology, Helmholtz Institute, Utrecht University, Heidelberglaan 1, 3584 CS Utrecht, The Netherlands 2Korsakoff Center Slingedael, Lelie Care Group, Rotterdam, The Netherlands 3Department of Bariatric Surgery, Franciscus Gasthuis, Rotterdam, The Netherlands Erik Oudman, Email: ln.uu@namduo.a.f. [https://www]Corresponding author. 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Happy birthday!!! Thanks for sharing! How alcohol is tolerated has been something I have wondered about. I am going on a cruise next August for my birthday (and celebrate my new me). Last time I went I got the alcohol package and drank, well, a lot (hey, it was vacation a decade ago;) ). I figure it won’t be worth it at all to get the package (especially since my husband doesn’t really drink much ) but I do plan on having some adult beverages for that 5 day cruise.