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Hi Oceanblue. What a pretty name. You bring back a lot of memories. It has ALSO been a long time since I have been on this site, and, quite frankly, I have been avoiding it. I started this topic of "looking for October friends" way back in October, 2011 before my Sleeve Operation (one day before your operation) and well, "petered out" in my posts to this site after I had lost close to 100 pounds in just about 6 months! It was really wonderful way back then -- losing all that weight. But, like you, that wonderful fast downhill journey didn't last for all that long. I have a lot of your same problems with craving carbs (especially sweets) and being hungry. Weight started creeping up slowly. I started at 309 pounds and went down to 209 pounds with a goal of 160. I, also, remember those first 10 pounds gained. But I was not so lucky to stop at that. You are doing much better than me. I managed to add another 16 pounds to that and am now at around 235. So I am pretty concerned as well. I started to see a psychologist and continued going to the Weight Loss Center at Mass General Hospital to see the people there for support, but have been in constant struggle for this past year. I remember feeling SO THIN after I lost the 100 pounds, and NOW I feel fat! It is so funny how we see ourselves. So I was actually happy to see your entry on this website even though I hardly even recognize this website anymore. I think I will need to start using it again and, like you, start reaching out for support. I don't know what this "5 day pouch test" is, but it doesn't sound good to me. It sounds too much like a diet and for me, diets ALWAYS means weight gain afterwards. The only cure, I think, is learning how to cut down on the carbs and sweets. Sugar is the real culprit. I have made a couple of efforts at curbing my sugar cravings by substituting fruit, which actually worked for awhile, but I somehow fell into my emotional eating pattern again, and the sweets came back. I wish I could offer you some help or advice now, but I am in your same position, only with more weight gained since my operation. I will have to look for help for the "old-timers" who have maintained their sleeved weight for a long time. But for now, I just want to tell you that I totally understand and perhaps we can support each other in overcoming this road-block to our weight loss and health goals! All the best wishes for a happy Thanksgiving and a little turkey and veggies and tiny dessert! I like to remember that Thanksgiving is only a one-day event! Let me know how you are doing. Hopefulspirit

Ditto!! I was also scheduled for the RNY, but cancelled 10 days prior to surgery…..for the same exact reasons. Though I added plication to my band surgery, I still sleep much better knowing that it can all be reversed. Once the other surgeries are done, they're done…..no going back. I know of too many who've had major Iron deficiency issues with the RNY, and the margin for weight gain over time is equal among all surgeries. Given that, I went with the least invasive.

Why would he yell at you??? For having a medical condition, as Reflux? Your story just goes to prove that Weight Loss comes from the band...Why else did we go through this surgery??? You were doing fine, had a few fills, lost weight......THEN because of problems beyond your control, you had fluid taken out, Thus weight gain....Proves it is the band...I know for a fact I could not loose weight on my own without the band...I'm doing fine right now, but if I should get the slightest fluid take out, it would disrupt this perfect balance.... On the subject of reflux...it is a common theme among banded people....I know I had / have my issues with it....but I have learned to control it by not eating foods that are too spicy....or to eat near bedtime. I won't eat anything after 7pm.... My biggest problem is I can't give up my Bloody Mary's....and I never mix food and Alcohol so it's always on a empty stomach...

First off, I'm so glad your hubby is completely on board- he's the person that's in the house with you and will be the person you really need on your side. As far as the other people in your life, they can have a seat. Your adult choices-especially ones you're making to benefit your health- are none of their business, especially your boss! How does she know what's right for you? Has she been a friend your whole life and is she there through all your weight struggles? On top of that- this sleeve is NOT easy. It's easier to do weight watchers and have a day where you "cheat" then get back on the wagon. But what would happen-your weight would continue to fluctuate up and down and you would be in the same position or worse this time next year. Right now if I didn't have my sleeve and I was doing some other program, I GUARANTEE I would've cheated and had something I wasn't supposed to. Having the sleeve and knowing something may possibly make me sick is deterrent enough for me- that was part of my personal reasons for getting the sleeve in addition to weight loss and having something in place to help me keep off/ control weight gain long term. The people who are saying these things to you should do some research on the sleeve before they chime in on what you should/shouldn't be doing. I would be willing to bet if you countered their opinion by asking them what they know about the surgery they couldn't even tell you what it is. And for sure the weight doesn't just fall off- you still have to work out to see good progress. Your supposed to exercise 60-90 minutes daily with this in addition to trying to drink all your water, all your protein, and take all the vitamins. Some people get the surgery and lose a small amount of weight and then nothing else (now that we're all together, I came upon a sleeve to bypass revision thread). Easy- I definitely don't think so. You could not be more correct barb! I shouldn't be letting these people who dont fully understand my situation try and use there opinions to change my mind, when exactly they have no idea what the surgery or the future of someone having a sleeve done entails! but thats why its soo nice having other people who understand your situation to talk to! so my next question would be have any of you tried progressive veg essentials? what are your takes on vegan shakes or non whey protien shakes. Im curious what all of you guys think of them?!

I know you're frustrated, but this is a good thing. If your thyroid is out of whack then you will need to be on medications to correct it. Otherwise, you won't lose weight even with the Lap Band. Unfortunately, just because you lose weight doesn't necessarily mean you'll be off all meds anyway. That's especially true when the damage to the body is already done or can't be fixed by weight loss. Thyroid issues are often not fixed by weight loss, in fact they are what causes the weight gain to begin with. Your doctor is doing the right thing. Be patient, it's all in your best interest.

First off, I'm so glad your hubby is completely on board- he's the person that's in the house with you and will be the person you really need on your side. As far as the other people in your life, they can have a seat. Your adult choices-especially ones you're making to benefit your health- are none of their business, especially your boss! How does she know what's right for you? Has she been a friend your whole life and is she there through all your weight struggles? On top of that- this sleeve is NOT easy. It's easier to do weight watchers and have a day where you "cheat" then get back on the wagon. But what would happen-your weight would continue to fluctuate up and down and you would be in the same position or worse this time next year. Right now if I didn't have my sleeve and I was doing some other program, I GUARANTEE I would've cheated and had something I wasn't supposed to. Having the sleeve and knowing something may possibly make me sick is deterrent enough for me- that was part of my personal reasons for getting the sleeve in addition to weight loss and having something in place to help me keep off/ control weight gain long term. The people who are saying these things to you should do some research on the sleeve before they chime in on what you should/shouldn't be doing. I would be willing to bet if you countered their opinion by asking them what they know about the surgery they couldn't even tell you what it is. And for sure the weight doesn't just fall off- you still have to work out to see good progress. Your supposed to exercise 60-90 minutes daily with this in addition to trying to drink all your water, all your protein, and take all the vitamins. Some people get the surgery and lose a small amount of weight and then nothing else (now that we're all together, I came upon a sleeve to bypass revision thread). Easy- I definitely don't think so.

Nope no soda for me. It was a bummer and I still on occasion really want one but I don't partake. I too have read the information that diet soda does cause weight gain. More than anything I gave it up and don't want to start it back up. I have taken to drinking tea and half decaf coffee (1 in the morning) and obviously Water.

My surgeon considers me a slow healer. Not necessarily the incisions, but my energy/feeling good level. I think my incision scars look as good or better then typical from a healing perspective. I would say that was true after my VSG too. I took 3 weeks off from work - I have a somewhat stressful desk job - and I wound up needing to take a few more days because i was so tired. I am not sure if i am a slow healer, or just complain more. I tend to "worry" about medical stuff so notice every little thing...lol Maybe my mental attitude and uncomfortableness with all things medical makes it harder for me? not sure. My arm incisions have been tingling a little. I emailed the surgeon about it and he told me that is just nerve recovery but it is happening a little later for me then some other patients - I guess more evidence for him I am slow healer. Thing is, I get lots of Protein and am fit, I feel like I SHOULD be a fast healer but that is my reality. I think in hindsight I should have allowed myself more carbs and stuff during my recovery but I am doing so little activity I worried about weight gain. So now I am cleared to ditch the compression garments and start working out. i am still wearing the garments because I like that I am not swollen and want to keep it that way and I am going to go really slow with the exercise. I am very focused on NOT putting tension on my scars with the goal of giving them the best chance to heal to a thin line.

Are you logging your food? Need to see how much Protein you are taking in, how many carbs, and then calorie count. Your metabolism might be in starvation mode and you may have to jump start it by increasing your food intake. Also make sure you are excerising. I've been stalled for three weeks, put on two pounds, and now back down and am hoping it continues to drop. But I'm a slow loser as don't have much weight to lose, so it will take more time for me to get those nasty pounds off. But I can't stress enough your need to log your food intake and make sure you get all your fluids in. I look at a stall like I did with my diets and weight gain. Yo-yo instead of up and down with weight gain and weight loss, now I yo-yo food intake and if it weren't for My Fitness Pal where I can log and it calculates I would be at a loss.

Normal weight gain for a bandster would be what any other normal person's weight gain would be. I gained about 50 lbs but I had half my fluid removed at 10 weeks and had no restriction. I think you are doing just fine!

I truly believe genetics play a role in obesity, also LIFESTYLE plays a huge role as well. Take for instance an Obese family -- They may never exercise, eat very high calorie foods daily, burger, fries, cakes, donuts, pizza, Pasta, fried foods, etc. -- I believe THIS type of obesity comes from eating the wrong foods and not exercising. Some people ARE TRULY naturally thin -- have high metabolisms, some people have medical conditions that make them naturally thin, I've known a few Type 1 diabetics, to be naturally thin, some people with chron's disease and have to frequent the bathroom, are thinner because more is leaving the body than staying in....so SOME people have illness that MAKE them thin....such as some people have illness that can cause weight gain. Some people will say some thin people eat what they want and never gain weight, but if you REALLY watch those thin people they do NOT eat that often, I have a niece that has always been thin and she eats junk all the time, HOWEVER, she barely eats food if you watch her carefully. She may eat a GOOD meal once or twice a week. But if you track most OBESE people and what they eat they are CONSTANTLY EATING, regardless if it is healthy food or junk. So I believe genetics has some play into obesity, but CALORIES IN AND CALORIES OUT, and what we eat -- and exercise plays a huge roles in obesity...

Thanks Border for understanding. I guess it is a fear of the unknown when it comes to that particular doctor visit as well as having to pay someone to judge us for any psychological fitness. Know what I mean? It's already difficult when people are judging us for weight gain and then this, it's just another difficult appointment that I have dreaded. I will be calling Monday to make my appointment but now I think I will have a little more confidence when I go. Good luck Border.

Most people who choose to undergo Lap Band surgery, do so because they want to change their body and improve their health. Most people understand what to eat to lose weight, however you need to understand how to do this in conjunction with the Lap Band. The Lap Band can behave slightly differently each day creating variability in the food you can tolerate. The most important consideration is to ensure that the Lap Band falls within the green zone. That is, the Lap Band is not too tight. Clients do come to me frustrated that they are not losing weight quickly enough. My response always is; what is holding you back? The band or you? I often get a confused looking client in front me. This question can be quite confronting and forces one to self-reflect and be honest with themselves. I believe honesty is the best policy. With this article I would like to discuss a common challenge faced by most lapbanders, how much and how often one should eat? My philosophy is to keep things simple and easy to digest. Realistically I like to see a minimum of three meals a day consumed. Rather than focusing on how much to eat, try and place the focus on eating quality healthy food that would fit on a small toddler portion plate. This portion should take 15 to 20mins maximum to eat, after which you should feel disinterested in eating more food and be happy to stop eating. Remember, it is not the role of the Lap Band to stop you from eating, this is your responsibility. Ask yourself, are you really using the Lap Band to its maximum potential? Happy eating Helen Bauzon If interested, on Wednesday night 27th November, I will be running a 30min live webinar where you can ask me any question, plus learn a key activity you can do to prevent weight gain during the festive season. http://weightlosssurgerydiet.com.au/index.php/online-webinars

Clients do come to me frustrated that they are not losing weight quickly enough. My response always is; what is holding you back? The band or you? Most people who choose to undergo Lap Band surgery, do so because they want to change their body and improve their health. Most people understand what to eat to lose weight, however you need to understand how to do this in conjunction with the Lap Band. The Lap Band can behave slightly differently each day creating variability in the food you can tolerate. The most important consideration is to ensure that the Lap Band falls within the green zone. That is, the Lap Band is not too tight. Clients do come to me frustrated that they are not losing weight quickly enough. My response always is; what is holding you back? The band or you? I often get a confused looking client in front me. This question can be quite confronting and forces one to self-reflect and be honest with themselves. I believe honesty is the best policy. With this article I would like to discuss a common challenge faced by most lapbanders, how much and how often one should eat? My philosophy is to keep things simple and easy to digest. Realistically I like to see a minimum of three meals a day consumed. Rather than focusing on how much to eat, try and place the focus on eating quality healthy food that would fit on a small toddler portion plate. This portion should take 15 to 20mins maximum to eat, after which you should feel disinterested in eating more food and be happy to stop eating. Remember, it is not the role of the Lap Band to stop you from eating, this is your responsibility. Ask yourself, are you really using the Lap Band to its maximum potential? Happy eating Helen Bauzon If interested, on Wednesday night 27th November, I will be running a 30min live webinar where you can ask me any question, plus learn a key activity you can do to prevent weight gain during the festive season. http://weightlosssurgerydiet.com.au/index.php/online-webinars

Here is my experience with RNY. First, I had my original gastric bypass in January 2005 at the age of 24 with a starting weight of 249 lbs. I did great with no real problems. I never had a goal weight but I got to my stable weight at about 6 months (157 lbs.). My weight stayed the same till January of 2009 after my divorce. I did gain back about 75% of the weight I loss. It is 100% my fault. I could eat anything prior to weight gain but after the divorce when my entire life changed dramatically I started to eat more often and much more carry out/fast food. The weight came back quickly but I was in denial. This past July I decided to look into a revision. I met with a different surgeon that was a revision specialist. My pouch had obviously stretch. On October 31 I had my revision with a starting weight of 217 lbs. I am now 33 and my recovery has been very slow and painful. I have only lost 10 pounds but I have lost inches. I am struggling with Protein intake. I am positive that I can do this again and commit 100% as my life is drastically different and I actively participate in therapy. So in my nine years here is what I know: #1 You gain regain your weight if you stop following the eating rules. The pouch will stretch. #2 Vitamin deficiencies are very real and you MUST take Vitamins for life. You must also take bariatric vitamins. I will note this part was not true in, research wise in 2005. I developed a deficiency because I was told pills like Centrum and Citracal were just fine. I know now the importance of bariatric geared vitamins. #3 Once I got t to about a two years post op I forgot I even had the surgery because my eating habits were just natural. I didn't think about it. #4 I became extremely fertile after bypass and hormonal birth control didn't work. Most people here are under 3 years out so I hope my story tells a more long term view. I am not a model patient. I admit I did not have to try very hard to lose my weight the first time. But on the other hand it didn't take much to regain it back. For me I went back to letting food be my emotional crunch and coping tool. Now that I have that under control I can be successful. I am 110% delighted I had my original surgery in 2005. Even though I am not having an easy time this go around I know that I am older now but I know what is down the road for me. This keeps me in check.

No who are banded. I am just curious what a normal weight gain should be with someone who has undergone the procedure. My OB would like for me to eventually get another slight defill but I think I have gained properly as of now....That's why I was asking Sorry I know I'm new to the board so I don't want to sound pushy just noticed a few people read my post so was curious if maybe people were hesitant to reply due to me being new here

I'm really glad you got some Fluid removed. It sounds like you were definitely too tight. Here's a really great article Jean McMillan wrote called "Tighter Isn't Always Better". She explains why a too tight band isn't only dangerous but how it can hurt weight loss and even cause weight gain: http://www.bariatricpal.com/topic/161269-tighter-isnt-always-better/ My two year band anniversary is coming up in January but I personally haven't had any of those issues. I tend to be extremely cautious about my band and not over filling it. Thankfully, my surgeon is too. Best wishes.

Hello! I am new to the board and had a few questions. I am currently 24.5 weeks pg with my 3rd child. I was banded back in 2011 and lost all and some of my weight. I had very high blood pressure issues but not extremely over weight and so was considered a candidate for the surgery. I started out this pg at 115 lbs and am now sitting at 132.5 lbs. I had a slight defill done in my first trimester (1cc was filled to 7.5cc's so I'm still at 6.5cc's about).... So my question is how much totaly weight did everyone gain during there pg's? I find I am still restricted to a certain amount and have a hard time eating certain Proteins, rice and dry things.....I am not really wanting to get a defill as I find I am gaining a sifficiant amount of weight.........How did all you ladies make out in that department? I am noticing I am eating alot of ice cream and chocolate at night.....lol......My cravings....lol

I'm so excited...I woke up this morning and after a couple of weeks of plateuing and teetering with weight gain I'm losing again, pretty big time too. I am now the weight I was during my sophomore/junior high school years. Yay me!

I relied on sweets cake mostly ( my husband would buy me a whole cake sometimes when I asked for a piece. I never complained mind you) and I would eat it in 2 days. Thank you for being a reasonable voice here also!! Anger is not bad your right! I just felt like I have no valid reason to be so mad. All the reasons you mentioned are prefect examples of why it's ok to be angered sometimes. I am being treated differently if I really think into it. More people look you in the eye. I have even got longer looks from men (and to be honest I really don't like it) But that's just me now. I don't know what to do when I get those looks. My husband and I had a talk about what may have triggered my weight gain. We pinned the start of it back when he was in the military and his soldiers would (apprise) me more than I was comfortable. He was fine with it knew I loved him and I'm sure felt proud in some way. It was shortly after a night where a few said I was acting in a way I would never act. (It was how they seen it in there eyes) I was just being me. My husband was amazed they thought that. And I must have in my head freaked out. I started to gain to keep the unwanted attractions away. MMM I haven't thought bout that in so long. Anger at missing the last 5 years. Holding me back from functions, activities I enjoy is another. I am thinking about things I haven't in years. You all are such a huge help! I feel like this is therapy and I must need it because releasing these thought free in my head are helping me understand myself more again! I suppose that's why we call it a support site!

Hi I've been banded since 8-23-13. I haven't done real well about 24 lbs. But I take 29 pills a day some are weight gaining and I've not had a fill yet. Do you know when lapbandtalk.com switched to bariatricpal.com? I havent6 found it in over 3 weeks. Just dense I guess. Anyhow the way I fiund my dr ( Grossbard) by googling. I'm sure you know how to do that but also call other drs to ask for recommendatons. Good luck on your journey.

I know about thinking about the outcome instead of the journey...We are all so excited about it being our turn to succeed with WLS that most of us never think of the journey...I know now that the journey is long and full of uncertainty regarding the day to day struggles of the ups and downs of fixing the real problems that caused us to depend on food as our support system.... I am so glad for your comments as regards the encouragement that was given here...Your a trooper and you will get it together.....To be in fear is a good thing really because you will never take it for granted....Share your journey with your loved ones as you become an example for them to lean on even in other things in life besides weight gain or loss.... Depression is something that is as unique as the individual who suffers from it...It takes time for the meds to really settle into your system and for the results of the strain from going into the depression to pass or get better even a little or a lot depending on you.... Use what you can to get through this part of the journey...Find the inner strength that I know you can muster and if you need extra help we are here for you...message me if you need to...k.. You got this kid...Your soon going to get through this and see the changes and the reasons why you did such a drastic thing and be happy you did.... Give out extra hugs and kisses tonight and make them count....K

HHib

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 didn't eat huge quantities but ate very rich meals and liquid supplements(eg- copious amounts of wines and the occasional cocktails) while in business meetings and while traveling or dining out with my wife, family and or friends. My long hours and not sticking to workouts aided in my weight gain. I did the 5:30am workout for awhile and lost 60lbs. When I stopped hitting the gym, I regained 70lbs.