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Congrats! There are some ladies on youtube who discuss pregnancy after WLS, Don't know how useful their info is... but you might want to check it out. Honestly, I would talk with your nutritionist. I am sure s/he can guide to to what to eat to promote a healthy baby... but not ruin your WLS. Your bariatric vitamins should have you covered as far as prenatal needs.. but your nutritionist can verify that as well.

@Frustr8 I understand, I really honestly do. I’ve spent most of my life with chronic pain, always fatigued and sick, always some new diagnosis or symptom. My main diagnosis has Bayan considered worse than HIV worse than cancer and causes something called post exertional malaise. It impacts every part of my body. It doesn’t matter my actual age my body feels old, there are people twice my age that feel younger than me. Not asking for pity for myself but that I understand you wanted the surgery and losing weight to make you feel good and not like a gastrointestinal cripple. Its hard. The smaller body is good but people look and think well then everything else must be good too. People didn’t think I needed to lose weight before surgery and now I’m sure they think I lost enough when I didn’t. They assume that you will also feel physically well. And you should expect to. But when you ask for help they look the other way. My head doesn’t work very well anymore, All I can say is can you see the bariatric surgeon and talk about the never ending nausea? That you still can’t enjoy food. I understand that feeling. On one hand I already had aversion to foods because of loss of ability to properly taste food and smell and always being nauseous but I could find things I liked sometimes and I could drink lots of water. I only really liked water. Now I can’t drink sips without feeling supremely sick. I try to drink ice tea and thinner shakes it’s the same. I was told thicken the water, yuck thicken water with some nice chemicals? Though the water thing probably isn’t because of the surgery. but not moving past the softest of “foods” can be truly frustrating. So I try to tell myself I don’t care and my nutritionist says I have to try as if it’s just a mental block and not a physical one. Im not trusting the whole balloon dilation now and expecting it to go back how it was (stricture) i knew going into this I would probably make my overall medical conditions worse but it was either fight for bariatric surgery to fight the rapid weight gain that even eating 800 calories of healthy food I couldn’t stop, or give up altogether. And even now I walk that thin line. And moments when my body feels literally like death and that would be easier. Yet I keep going and trying to take each step forward and trying to focus on the tiny goals of losing weight. Even though I will always feel like the bullied fat kid. You answered my message on my post but I needed to respond here first before I got too tired to say what I wanted to say. Please give things time, I know it’s hard. Get an appointment to speak to your surgeon and nutritionist and try to get that message across to them. You have a goal to reach and you just want to get there and also feel better too. I truly hope you do.

Hello all. It’s been a very long time since I’ve posted in here. I had sleeve in 4/2014. Was doing good, lost 80 lbs (definitely not as much as I needed to or hoped for) and as of 3 years ago I’ve developed server GERD and bad stomach pains. I’ve also had Achilles’ tendon repair surgery and a muscle tear surgery on my left elbow so my mobility has been very very limited. Achilles’ tendon surgery recovery time is exactly 1 year. And I had both done so to say the least, I’ve been home...not being able to do exercises at all, except resistance bands which I do do. So, with my weight gain all 80 plus more regain I’m exactly 22 lbs heavier than I was the day of my VSG surgery. I recently had an UGI and EGD done 2 weeks ago which showed severe GERD, gastritis and I have bleeding in my stomach as well the bariatric doctor said. He wants to do a revision to bypass which I’m very happy about, no more GERD and hopefully to get some weight off also. Question is; I’ve already checked with my insurance company BCBS and they said I was certainly covered for a revision as long as I meet 2 of the 6 comorbities and I meet 3. I had them send me the info on getting the revision and I’ve read it throughly and it says in it that if my doctor suggests that I do the nutrition classes prior to surgery then I have to. I am going to express to my bariatric doctor that this pain is unbearable and can he please do it ASAP. How long did y’all have to wait for your revision from getting your testing/procedure results back? Did your bariatric doctor make you go through all the nutritional classes all over again? I’m really really hoping that he doesn’t make me do these classes because I’ve already met my annual deductible and this whole revision bypass surgery will be fully covered 100% and I will have zero money to pay. Please tell me there’s hope. My next appointment with him is on October 29th so I’m praying he will give me some excellent news. I’m going to stress to him about my insurance as well. TIA for any feedback

Congratulations! You are lucky. I was miserable for 36 hours after surgery with nausea and pain. I had major surgery on my head/neck previously and thought this would be no sweat but I was wrong! I’m glad i didn’t know ahead of time how awful I’d feel. Guess it’s different for everybody. Anyway, the nurses told me that with Bariatric surgery you usually just feel better and better, not worse. So it looks like you might be free and clear as long as you stick to the post op diet. Good luck 👍

In terms of the fluids... don't worry too much, they go through you. I can drink quite fast... but I can't eat more than 4 ounces of anything. When I do eat 4 oz, it is something with fluid in it (like soup/chili). I can't eat that much of solid food. I am one month post op. Dr. Vuong (youtube bariatric surgeon guru) says it is natural for your body to feel hunger. It is not natural to feel full. Makes sense when you think about it. Fight the urge to overeat. It is OK to feel hunger. And I am still not sure if what I am feeling is hunger or just my stomach still churning a bit after surgery. Seems like both feel pretty similar. Look the doc up on youtube... he has some great videos. I like him so much I bought some of his cookbooks and gastric sleeve info books.

And May You Work to make It so- I have passed Doctor's Goal- anything below 200 but I am still trying for My Dream of 175- so so close- really am hating My At3as of Gauntness- 2 of my,Major Doctors SAY I'm Looking Fine- but I am Doubting Myself at This Point- maybe a Crisis of Spirit- it the Emesis, underlying pain and the knowledge I inately now feel " Gastrointestinally Crippled" and it is a Life Sentence without Parole, maybe it is time to seek some Bariatric type consultation SOMEWHERE- people keep saying "I'm Just Fine" nobody actually seems to Listen- and a Niggl8ng Voice wisps for the days of Tummy satifactionn oh it Wasn't Always" Binge City" for Me- I just wish i DIDN'T HURT ANY MORE- yeah the scale does Read Lovely but have I, like the Biblical Esau, sold my soul for A Bowl of Pottage_ And were the deminishment of size worth the pain and perpetual nausea state I have now? I went into this to regain health NOT to lose it in the process- the Brave Little Cowgirl is feeling Midnight Blue this AM- even watched the Bypass reversal. Videos on YouTube- DON'T Think I'M QUITE THERE YET but am teetering towards- even IF it killed me and an Open Abdominal surgery at 73 just COULD I might die with the sense of peace I don't feel TODAY- I am weary of the struggle, my friends, and too too depressed over what I elected to have done to ME. But I can't commit to suicide for ME - I couldn't hurt my family, friends and BP friends by THIS, my uncle did kill himself before I was born and my Daddy carried emotional scars to his own death 50+ years later, mourned his brother that was his "Irish Twin" only 11 months between them and when He told me of Uncle Clement, He Cri3d and I did TOO-! So where does One go from Here? Sorry to Vent- maybe there is PEACE Ahead? Some Say :Give Yourself at least 18 months to Feel Healed" Well I'm still less than That, maybe I will be Okay?

I only went to the hospital twice before my op. The first one was when I discussed the idea with the surgeon and made my decision. The second one was when I went to see a nurse a week before the op: she weighed me and took some bloods. I was in and out in 10 minutes! It sounds quite abrupt, but I did have good support afterwards: I can speak to a bariatric nurse whenever I want to.

I’m 44 and in Portland, Oregon. I’m in the pre-surgery stage. I’ve lost 50lb since May just in changing my habits in prep for surgery. I have a bit over 150 to lose still. My insurance only does Gastric Bypass. I have my first meeting with the bariatric department on October 11th. No surgery date yet.

Gastric bypass surgery ended up being the choice due to severe GERD, metabolic disorders and extremely slow metabolism. My nutritionist gave a list of brands for protein and vitamins, but it’s a suggestion not a rule. As long as you get the protein and vitamins you need and there isn’t too much sugar. Usually no more than 4 grams. I think my papers said no gummy vitamins but I did my research to find a combination to work for me and showed my nutritionist and she said it’s fine. She is a nutritionist that works with my bariatric surgeon. But she is also open to new ideas that might be helpful for the bariatric patients she sees. She does nutrition classes for bariatric patients. I was required to attend before surgery. The difference between sleeve and bypass is less about amount restriction but more the bypassing of part of the small intestine and rerouting of digestive juices. If your gut says RNY Stick with RNY and you will do great.

Well, spent the night at Bariatric Pal hospital. I’m set for surgery at 9am. I’m very excited. The nurse and concierge came in and told me that I am ready to go. So, now I just wait.

Thank you for such an honest account of your experience so far! I am coming up on my revision from band to bypass, so i have some idea of what to expect, but know it'll be very different still. It's been many years since my band, so it's good to have some reminders of things I can't remember from all those years ago. A bariatric budget is a really good thing to be talking about! I don't think most people know the extent of how expensive it can get to get all of your nutrients in! There is a brand of protein shakes that may work for you, Syntrax Nectar. They seem to have a lot of fruit flavors for people like us who don't want to drink thick chocolate flavors every day. I have not tried them yet, so I can't speak to how great they are, but the reviews look good! I have a few samples from them sitting in my BariatricPal cart to order, so I can always get in touch once I try them! I also thin out my protein drinks with extra almond milk I want to be able to drink my protein shakes easily not feel like I'm putting a ton of work into it. Or you could try using the unflavored protein powder in various liquids and pureed foods! It sounds like despite the pain, you are doing great things, it looks like you are moving well and really have a grasp on what's going on. You are going to be super successful, I just know it! Keep up the great work 😃

I am on several private Facebook groups. Their posts are not open to the public, only the "Cover Page" that explains the purpose of the group. You have to be admitted to the forum by an administrator and can be kicked out, as well. I just asked to be admitted to another one for bariatric recipes yesterday. You do, however, have to use your real Facebook name. The only downside to forums like that is that someone has to have the time/willingness to be the admin.

the stuff the dietitian told you is puzzling. She must not have much experience with bariatric patients. First, you have to take vitamins for the rest of your life regardless of which surgery you have. And yes - it seems overwhelming at first, but you get used to the routine very quickly. I don't find the vitamin routine difficult or confusing AT ALL. I'm pretty much on autopilot with them. also, the 1/4 C thing is really just during the first few weeks after surgery. At four years out, although my portion sizes are that of a standard "light eater", they're not 1/4 C or anywhere near as restrictive as they were for the first few weeks or months post-surgery. No one would be able to tell anymore that I'm a gastric bypass patient if they were to watch me eat. I eat about the same amount as my "light eater" normal weight friends - which is of course much less than what I ate pre-surgery - but certainly more than 1/4 C. For example, for lunch today I plan to have half a turkey sandwich and a side salad with light dressing. For dinner I'm thinking a "Beyond Meat" sausage with sauerkraut wrapped up in a Flat Out Fold It wrap....maybe with another side salad (although one of those sausages usually fills me up - so I may skip the salad). About 3 oz of meat plus some vegetables or a side salad with light dressing is a pretty standard dinner. At restaurants I'll often order an appetizer - or if I'm really hungry, I'll get an entree and take half of it home. Really no different than my normal weight friends who are watching their calories. so suffice it to say, you're getting incorrect info from that dietitian. She must have some bias toward the sleeve - or just hasn't really worked with bariatric patients before. Edited to add that I've been hanging out on various bariatric boards for about five years. The diets for sleeve and bypass patients are the same - both early post-op and years out. As for vitamins, some surgeons have VSG patients taking fewer than bypass patients (but others, like mine, have them on the exact same vitamin regimen). But either way, you are taking vitamins for life. Pardon my French, but I think the dietitian you saw is full of crap...

Not sure if this is allowed, but I have a box of Beef Bone Broth never open all 4 are still in the box, 3 Chicken bone broth. I used one, but they are all individually sealed its the orange package. 3 other broths which is Cream of Tomato, Chicken soup, and chicken with pasta (all broths). I have two protein powders. One is Coffee and the other is Double chocolate fudge. Also a Bariatric Pal plastic mug you heat the broths in. So total of 10 broths, 2 shakes, 1 mug. I bought all of this off Bariatric Pal and they are left over from my 2wk liquid diet. I'm not gonna use them so they are just sitting here. If you live close and willing to meet near me somewhere then they are yours for free! I know how costly it is getting ready for the 2wk liquid faze and the first month after surgery! So let me know. I won't hold for anyone (sorry) unless we are meeting of course. So its whomever can meet first. Thanks! (delete if not allowed) Sent from my SM-G965U using BariatricPal mobile app

My surgery was rescheduled from Sept 23 to Oct 15. No liquid diet, just continuing to eat clean plant-based whole foods. Possibly am some sort of bariatric alien because I feel a bit envious of the Opti-Fasters. I love protein powder mixed with plain water and am actually looking forward to not having to bother much with food and food preparation for a couple of months after surgery. All the very best wishes to my fellow Oct sleevers 😊

I was part of a research study, while on a medically supervised weight loss program with optifast. this was in the 1990s, long before I had bariatric surgery. It is not the surgery that causes the problem. It is the rapid weightloss. People who loose large amounts of fat, over a relatively short period of time, can have complications with gallbladders. So, it could be prudent to remove it while having weight loss surgery to avoid having to have another surgery.

UGH! I received another call from Sage Bariatric on 9/26/19. My pre-authorization has been approved, but still waiting on the approval for the predetermination. So I google BCBS pre-authorization and predetermination, because I was really confused. Pre-authorization or pre-notification, pre-certification confirms that a physicians’ plan of treatment meets medical necessity criteria under the applicable health benefit plan. A predetermination is a voluntary, written request by a provider to determine if a proposed treatment or service is covered under a patient’s health benefit plan. Predetermination approvals and denials are usually based on our medical policies. It has been two week and this waiting is really kicking my butt. But on the upside. I have gotten some much needed cleaning done trying to stay busy when i get off of work. I am so thankful i found this sight, I just really needed to think-out-loud.

I personally feel that getting a GOOD therapist/counselor that works with people that have food addictions is critical. You have done the 'first step' as the 12 step programs say and have admitted you have an addiction. This is ONLY my opinion, but when I had that same mindset that you openly and honestly admitted (and kudos for that!), I KNEW I was not yet ready for bariatric surgery no matter how many doctors in the past decade urged me to do it immediately. I also knew from long ago experiences with other addictions that I could "intentionally" make someone believe I'm ready OR..that someone, likely a counselor/therapist may pass me off as 'ready'..but I would not be. Postponing surgery while you work on your journey is NOT giving up. In the end, I hope whatever decision is made, that you are at peace with it. We will all encourage you. Delaying does not mean NEVER. And am not sure how soon your surgery is slated for...if it is months away, you have time to get a little extra help.. This is different than just the normal fear of failure. I was NOT ready to give up my addiction until 7 or 8 months ago and that was after looking into overall..honestly it was 5 years with 3 of those spent on this board in silent mode. People with addictions all have different 'bottoms' and for some ppl, they don't require hitting bottom. in order to realize that they were finally ready to do WHATEVER it took. Unfortunately, I was a stubborn/stuck in and loving and hating my addiction. Could you have surgery even with how you are feeling and have some measure of success...well, there are ppl here who did. I feel like though...it would be what I call 'white knuckle' recovery. This journey is amazing but it can also be very hard, especially the first 3 to 6 months. I do know that an overwhelming huge majority ALL wish they had done it sooner. I am in that number. However, for whatever reason, I was not ready. This also does NOT mean you cannot become ready faster than my stubborn self did! Seek out someone that works with food addictions, WLS and they are good at it. Find a great person who helps you challenge and overcome your current feelings of not being ready..and when you are ready, they will help you know that you are.

I gained weight after my initial visit to the bariatric surgeon. I wanted to eat everything that I wouldn’t be able to eat after. I didn’t fail, it took me longer than most and I went through some things, but ultimately succeeded and feel better than I have in years. I did have to change everything about the way I was eating. Some people can just eat smaller portions of all the food and lose the weight, but I am not one of those people. For me, getting the surgery was the help I needed. What if you succeed?

Wow. What does thiamine deficiency have to do with the topic of this thread? That’s an awful lot of medical jargon mixed with scare tactics of posting it in a thread that has nothing to do with vitamin deficiency. I have complex lifelong chronic illness which includes neuroimmune/immunodeficiency. Basically it effects every aspect of my body. I also have neurological symptoms starting long before surgery. I take a series of gummy vitamins. My last bloodwork by my bariatric surgeon my thiamine aka B1 was within the normal range. Just take the right vitamins that have good bioavailability (whole food based, chewable or liquid form) and have regular bloodwork and there is no need to panic about vitamin levels. Besides an issue with iron and some bloodwork that could indicate anemia (which I’ve had issue with before surgery) my blood vitamin levels have been fine so far. Even my extremely low vitamin D is in normal range now. Low thiamene isn’t going to instantly cause some life threatening neurological disease. If your doctor says it’s low, take the vitamin. Or just take a good food based b complex as prevention. I e studied holistic heath, nutrition and vitamins. Do I remember everything. No my memory sucks but it’s crazy to post a long medical research report and not even on the appropriate topic. Sorry if I’m rather touchy today. Taking a basic multivitamin isn’t enough especially tablets like centrum or any tablet that might not get properly utilized by the body is probably not enough. One of the things about gastric bypass surgery is an investment in our health and making sure to get the right vitamins and nutrition. But I’ll shut up. I got flack because I said I take gummy vitamins and too many. Just do your best and don’t worry about thiamene deficiency unless your doctor says it’s low and it’s easy enough to get a natures way alive b complex vitamin at the grocery store.

No problem! I am glad I was able to help. As a side note, I also recommend watching Dr. Duc C. Vuong's video's. He is a bariatric surgeon that has a lot of videos that I found really helpful. Here is a link to his youtube channel: https://www.youtube.com/user/DoctorVuong

I’ve been taking things in stride as best I can but am rather miffed at doctors and events today so I am just going to rant even though I need to be trying to sleep. Prior to my gastric bypass surgery and gallbladder removal My gastroenterologist insisted I have a colonoscopy due to the fact that previous ct scan had shown severe narrowing of my colon and a recent ct showed possible colitis. But the colonoscopy had to wait until after my surgery. I went through three days of clear liquids and hellish prep trying to swallow the required liquids. While the nurse was great I was literally the last patient and they were already starting to close down the facility before my procedure started. I had an unusually hard time waking up from the sedation and just wanted to close my eyes but they were in a hurry to get me out, I was barely awake and told to get dressed and get in the car to go even though I was stumbling and could hardly walk. I didn’t get answers from the colonoscopy. I don’t know if endometriosis can be confused for colitis. But why would a ct scan show something but not a colonoscopy. It showed melanosis in the colon usually caused by chronic laxative use which I refuse to use laxatives on a regular basis so rarely take it. Also diverticulosis of the sigmoid colon which has been there some years now and the last doctor just said well you have to wait until you end up in the Er with an emergency to even do anything. Like ok. But no biopsy was taken of the darkened spots of my colon. And no explanation of my symptoms. My bariatric surgeon said My gastroenterologist could do the endoscopy since he is closer to where I live, and he got all my information and everything. I had previously had a balloon dilation of a very narrow stricture. They saw the stricture during this procedure (so I guess the previous dilation didn’t do anything) but my endoscopy report reads: “ge junction with mucosal tear from hiccup during dilation” I didn’t speak to the doctor, I wasn’t alert enough. He made it out like nothing to my mom. They didn’t take any biopsy from either tests. And I have a mucosal tear but not what to do about all the pain? Im just tired and frustrated. I can only manage so much when I don’t have clear answers. I have to have another procedure this time a surgery in two weeks to do with the endometriosis. Not even sure the doctor will be able to find where it is since it can be anywhere and the main reason is my ovary has to come out. All my long rambling, sorry. Has anyone had a tear happen during a balloon dilation? From what I see dilation isn’t a cure just a treatment or temporary fix. I know you don’t want the stoma too big but too small is not good either. I’ve been having spasms in my left side, crushing chest pain, nausea and difficulty with purée and other symptoms. I’m the end I just shut up and deal with it. Im not regretting RNY because with my nonexistent metabolism I would not have lost nearly 63lbs. And I knew it would take its toll on my chronic illness but so much at once has me exhausted. end of rant.

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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TGIF!!!!!!![emoji119][emoji119][emoji119] This was a helluva week!!!🥵 Day 24, 25 and 26 Hubby and I did date night last weekend. It was lovely! I'm not on any social media other than Bariatric pal by choice! So nothing to unfollow. I definitely said no to writing a blog for work. I'm typically the go to person for the blogs but I was TRULY swamped this week so it was a "HECK NO"!! Moment when I was asked! No guilt too!! Day 27: I'm using my phone as we speak so hard for it to be a phone free night. I may drop it when I'm done writing this[emoji2].....but then again, I'm on call tonight so no can't do. Squats!! Was happy for rest day! From day 25 onwards, squats have been done in 2 events![emoji28] I'll complete the rest of my 95 later tonight. B side: My older sister is my absolute girl crush!! I 🧡 her!! She's admirable, courageous and FIERCE!!! Did I say TGIF??? Yay!! Sent from my SM-N960U using BariatricPal mobile app

Let me tell you a tale. lol. 9/21/19 - I wake up and immediately experience sharp, stabbing pain in my abdomen. It extends from my stomach down in a straight line. Soon after, I develop severe muscle soreness in my back. The pain is superficial; clearly muscular. It is tender to the touch. I decide MAYBE it is related to the gastric so I spend a few hours trying to go about my day. By 3PM I decide I need to go to the ER. I go to the closest ER to where I am. After 5 hours, they tell me they can't treat me because I complained of abdominal pain and they "don't treat bariatric patients". They have me transferred to the hospital that did my gastric bypass. - Cue $150 copay for no reason. 9/21/19 - Different ER. I get several doses of Dilaudid, to no effect. They do a CT scan and see my pouch and organs all look fine. Again, I express I have severe BACK pain and superficial abdominal pain. They call the bariatric surgeon on-call (not my surgeon) who says it's an ulcer. They do no diagnostics to confirm it's an ulcer. They discharge me with $100 in ulcer medicine and "a shot of Dilaudid to get me to my bed, at least". Cue 100$ in meds and $150 copay. 9/23/19 - I call my bariatric office and they fit me in as an emergency visit. The NP says it's definitely not an ulcer. DUH. He orders a back xray and abdominal xray. He prescribes me prescription NSAIDs and says to keep taking the ulcer medicine "anyways". Cue $50 copay. 9/24/19 - The bariatric office says no one is around to read my xrays. I have to sick my mother on them. LOL. They call me back immediately and say "they don't know what's wrong" and I could schedule an endoscopy to rule out bariatric issues. I tell them that is idiotic because I already have all the ulcer medicine. They agree. 9/25/19 - I attempt to go to work. I end up bursting into tears from the back pain. My PCP fits me in in the afternoon. She looks at my xrays and says I have degenerative disc disease from osteoarthritis and a thoracic hairline fracture, which may be more noticeable in an xray performed a week out from the injury. I do not need ulcer medicine. She sends me for a back brace, prescribes a strong muscle relaxer, and prednisone. 9/27/19 - I am back at work with no abdominal pain, but still excruciating back pain. I notice I have a gigantic red bruise straight down my spine and numerous purple bruises. No one has even looked at my back until I did this morning, so no doctor has even seen this. I call my PCP just to give her a status update. She is, of course, out of the office today. I continue to be in pain. BACK. PAIN. It is concluded that I likely injured myself with weight lifting at the gym on the 20th. None of this is bariatric-related, and I was pigeon-holed into a diagnosis without ANY diagnostics being completed because I happened to mention associated abdominal pain which was MUSCULAR but since I said "abdomen" no one wanted to touch me with a 10 foot pole because I am a bypass patient. I spent $500 for literally no reason, and had multiple hospitals and practitioners insist this was somehow bariatric related despite nothing lining up with any bariatric issue. Completely absurd. I should have insisted other diagnostics but I was in SO much pain for this past week, I wasn't even in the mindframe to argue. At first I thought MAYBE this was some freak ulcer thing, despite having ulcers before and knowing this ain't it. Anyways, I guess this is something to look out for in the future - that any remote mention of abdominal pain will trigger a complete shutdown of all common sense from medical providers that, hey, this isn't necessarily because this patient had gastric bypass and COULD be a f**king SPINAL FRACTURE.