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Because i was a revision Its taking me longer due to scar tissue.. Liquids for the most part are fine .. I get in probably 36 oz of liquid a day but I cant drink any protein .. it does not sit will with my stomach , I was revised on the 14th and still am not on mushy foods or pureed foods like most people. The closest I can eat and keep down are refried beans .. doc told me to just keep trying .

Oh no! It's too late! Don't worry about it. The best person to answer that question is you, and probably not until after you've had it for a while. If the band works for you, then it was the best procedure. If it doesn't work, and for the right reasons (i.e. you are doing everything you are supposed to) it can always be revised to a sleeve. But if it were me, I would not start out worrying I went the wrong route. Give it time.

I initially had the sleeve and was told I could maybe try it at 18 months out, but it was very heavily discouraged. I had a revision to bypass and was told absolutely no forever.

Well 1Cor, it DEF will happen, and yes it's a part of the process. But I hope that knowing that we've all been there and survived it will encourage you to just let it happen, keep working out and eating right, you're doing gr8! Just remember how b4 surgery, we gained, not stalled but gained and at least now after the surgery, you know that it too shall pass and Lord willing, you'll be back to losing. As much as we all dreaded it, it's actually a good thing for our bodies to be able to rejuvenate, recharge and reset after such massive weight losses. Although the docs, and praise God for them, had done something to our bodies to help us with significant weightloss, God made this temple and thank God that He won't allow more on our bodies than it can handle! Hopefully I gave encouragement to you and not just rambling on, at least that was my goal. I'm a revision from sleeve to bypass due to 2yrs suffering from vomiting due to severe acid reflux and a stricture and guess what, 3 weeks out exactly, my body stopped losing! It just has to happen:) and now I'm going on my 5th week and started back losing, not that that's my ultimate goal now but I still want to lose a little bit more. Take care and hang on and in there with us. We have your back!!

Hello all! Please add me to your group! I'm a band to bypass revision. Just got my date for March 21st! So Glad to have found all of you!

I am probably the grandma of the group. I am 60 and my grandson is 11 and my granddaughter is 9. Bought myself a bike a couple of years ago and then required a hip replacement and could not ride it. Turned out the hip did not heal well and I have been walking around with a loose rod in my leg for two years and it hurts. It was to have been revised on 10/26 and the cancelled it about an hour before I was to leave for the hospital as my surgeon and his partner were going to do it together at the smaller hospital, closer to me. It turned out that the hospital was simply not equipped for some things that are very likely to happen and it will be done at the big hospital across the state from me as soon as I heal well enough from the WLS. That is going to be a biggie and will haveme hobbling about on a walker for a long time. We go to music festivals in the summer and my goal is to be able to be without a walker and able to ride my bike. I had my husband put a basket on the front and folding side baskets over the back fender so I could use it to go to the local stores. Oh, and I see I even have a pink hat and a pink & purple horn.

Had my sleeve to DS revision. I was in OR like 8 hours. But I’m walking and takings sips of water and broth. Biggest pain is getting up and sitting down. Also had hiatal hernia repaired

I know we are all different, but I’m curious how much weight you’ve lost. I’m 5-weeks post op revision from vertical silastic ring to bypass. I’ve lost 26 pounds. Weight before pre-op diet: 240 Weight day of surgery: 230 Weight today: 214

Hi James and welcome! Congrats on your upcoming revision. I hope it goes smoothly and you are able to progress into your stages without complication!!! Woot! I think 2-3 months to start IF/EF is a bit ambitious. I'd target 6-9 months or until: 1. Your new tool stops working efficiently. Give it time to do its job. And really focus on maximizing YOUR part in its efficacy (ie making healthy choices, deeply nutritious and low calorie dense foods, exercise, follow your surgeon's plans, follow 30/30, take your vitamins, plan/weigh/measure/log every bite of food, weigh daily for accountability, no booze, etc). It's really important to make good choices, but to let your tool do the job its meant to do. Right? 2. You can easily get all your water in (around 100+oz day). 3. You can easily get all your protein needs met with real whole dense proteins. That's usually a 6-9month progression or longer. ****** But, you surely can do TRE (time restricted eating) to consume your foods in a 16:8 window. At first, even that will be a challenge for you. You do not want to over-consume your capacity at any time or in any stage. And if you are compressing your eating window, that risk of consuming larger meals to compensate exists. So a 16:8 might take you 3-4 months post surgery to be ready to do that--maybe even longer depending on your rate of healing and size of restriction. But even setting a 13- or 14hour fasting schedule would benefit you per Dr. Longo. And that's basically an overnight fast. ****** I don't know about doing a WF for pre-surgery. They usually want your liver emptied, but your protein levels high so you will be at an ideal healthy level for surgery. Pray about that and ask your RD. If I had it to do over again, I would definitely do a bowel prep and make sure I was 100% cleaned out. Gosh mine post surgery was ridiculously terrible. One of the only complications I experienced at 3 weeks. Rosemary's Baby bad. So I'd bowel prep about 3 days before surgery, then do clear liquids for the last 2 days presurgery, making sure you are getting all your electrolytes. ****** Here's Dr. Mindy Pelz's Resetter's Tribe on FB. https://www.facebook.com/groups/resetters/

They did both...it's definitely neurological...dont see that doc until sept.....it's a teaching hospital, so appt.s are super hard to get. I still need the graft in my neck stented or revised...I am, however, losing greatly... 15 lbs. To onederland!

Oh, and no, port revision surgery is not as bad as the whole band surgery. At least I didn't think it was. I had the revision on Saturday, back to work Monday. Don't recall any kind of recuperating time, just the damn leaking thing.

I went to see my doctor today. He put me under the fluro to check my band. The placememt is fine, no slippage. He did the barium swallow test and saw that it is taking me longer than normal to pass the liquid. He tried to do the unfill and couldn't get to my port because, not only has it moved to what seems to be a land far far away, it is also upside down. He is going to do the revision and cut the cathedar. Apparently since I have lost so much weight it is all curled around. It is outpatient, and I am going to sit patiently until he can squeeze me in. I'll keep you all updated!

The port issue is the problem I had. My port ripped up from the muscle. The pain was slight over time, and then became excruciating, which ended me up in the ER. That was the day the stitches must have actually come up. The initial pain was just leading up to the inevitable, I suppose. I had the revision surgery in August, but um, I don't think the stitches held that time either...shocking lol. I have little dumb problems ALL THE TIME. I figure I don't want to mess with the port much because it is somewhat of an advantage, in the event I want to have the band removed in time, I have an argument for insurance to cover the procedure. The pain is mild and irritating, but nothing debilitating. Next problem...why do I think my bad slipped? I hope I am being a hypochondriac (I am sure I didn't spell that right, but too lazy to spell check). Anyhow, the last few weeks I have difficulty getting even liquids down. Lately, with solid food, some time after I eat it, if I am sitting down it seems that the food has been broken down into a more liquid form and I begin to regurgitate and choke. And I suffer a lot of heartburn. I googled all these symptoms...and I find band slippage. GREAT!!! I see my not-so-helpful doctor on Friday. Um thank God it isn't an emergency! I'll keep you guys posted. 7....more....lbs. That's it lol

When Penni told me about her situation and that her surgeon was the same as Lisa's... RED flags went up immediately. I told Penni to come here and check out what was going on with Lisa because they seemed to be having a very similar problem. I do not think either of you should have to pay for these revisions... and something doesn't feel right about this situation at all to me. Lisa... I am also concerned about your waiting until this weekend with that tube protruding from your incision. I feel that is a direct line for bacteria to enter the abdominal cavity and I don't like it one bit... not one bit I say!!!!! It bothers me greatly that Dr. Lopez is also willing to wait until Saturday... did he see those pictures?????? I am also worried of course in regards to if this is a common complication... or if it is just common for Dr. Lopez or any specific surgeon. Actually... it is scaring the BAJESUS out of me. If anyone is able to obtain statistics about this... I would be eternally in your debt! Penni... I think you emailed me instead of Lisa... I got an email from you and it seemed to be directed at Lisa AKA DeLarla ??? Worried in Wisconsin... Darcy

"You're saying that we don't have to be baptised or go to church to get into heaven, right? And since we are all known by Jesus and God to be sinners, and he doesn't expect us to go through life without sinning, we don't have to worry that being a bad person or a sinner will keep us from getting into heaven just as long as we have faith in God?" I do believe that we don't have to go to church or get baptised in order to get to heaven. And we don't have to be perfect. God knows that none of us are perfect and that we are going to sin, it is our human nature. I don't have all the answers, I don't understand a lot of the Bible. I think the Bible has been edited and revised so much from its original version that it is almost imposible to understand. I do believe that all we have to do is repent from our sins and ask Jesus to come into our hearts and save us. And we have to be truthful, and honest and really mean it and really believe it. While we don't have to be perfect, I do believe that if we have truely asked forgiveness and have faith that Jesus has saved us, then we will want to live right and do good. I don't think it is a requirement to get into heaven, but if Jesus is living inside your heart, you will not want to do bad. You will want to live the best you can. But that doesn't mean we won't slip from time to time. And God knows this.

Im going from a sleeve to MGB june 19th with Dr Illan in mexico. I am wondering, for those of you that are revisions, if and when did you start actuallu feeling hunger sensations again after surgery? Like real hunger pains not head hunger. TIA. [emoji5]

First of all, I would meet with a bariatric surgeon, not a general surgeon. You want a bariatric surgeon because they see these issues regularly, and are at the top of their game with weight loss surgeries. Secondly, if you live in an area that has a university with medical school, find out which hospital they teach at and find a professor of bariatric surgery that is practicing and teaching. They are on the forefront of bariatric surgery. My bariatric surgeon is a professor and she told me that she does revisions that other bariatric surgeons won't touch. Don't take the general surgeons word for it. Seek second opinions with bariatric surgeons. Best wishes!

Hi Babygirl, This thread is really old, and I am pretty sure that Amerihealth has revised their coverage policies since 2003. The only way to tell is to call them and ask what the coverage criteria are for bariatric surgery. If it's an exclusion on your plan they'll tell you. Good luck!!

Hi kelliv, I am having a Bypass for a couple of reasons: I have had 2 x Lapbands which have slipped and I am having the second one removed in 2 days time. I have also had my Gallbladder removed during that time. I injured my back and both shoulders at work and I have had reconstructive surgery to my foot and today I was told that I have acute arthritis in that foot which I can hardly stand on at the moment, so exercise is going to be difficult post op. My Surgeon and I discussed my options and he feels that when he does the WLS it will be the 4th stomach operation that I have had, this means that I have a much higher risk of developing Scar tissue around my stomach, I need to lose at least 50kg and his statistics show that a Bypass should be more successful than a sleeve, he believes that if I have a 'sleeve' he will have to revise it in 2 years so he recommended doing a Bypass as the first option, I have a complicated medical history which includes lung clots last year and I am 57. So, after weighing up all the pro's and con's we decided that I would have a Bypass. I really like this forum and there doesn't seem to be a similar one for 'Bypassers' so I hang out in here. Hope you don't mind???? You all have amazing stories and insight into WLS and I have learnt a lot from this forum.

Mine is June 22nd. Up until last week I was set on the sleeve but due to my EGD it may be changed to bypass. I have my pre-op Thursday and will make a decision then. Trying to avoid getting the sleeve and then having to have a revision due to acid reflux later. Sent from my iPhone using the BariatricPal App

Hi Eddie! Welcome!!! I'm not a revision but I'm several months out and I have lost 63 pounds. I believe the sleeve is by far the best decision I have ever made. I Hope your revision journey is a smooth one. Keep us posted. Deb

I'm down 51 pounds (as of today)...So 2.5 months out from revision. I had only lost about 65 with the band...and regained all of it back (plus 20 pounds)...I'm so happy with my decision to revise Leslie

Congrats Amieru! I'll be thinking of you Tuesday morning. I had a really good experience overall in Parker and I hope that you do, too. Woofay, I am so sorry that you're feeling ill and hope that you're better soon. There's an awful flu going around here. I think it's possible you're not getting enough vitamins/healthy food, but it could also just be bad luck. You work at a school, right? I never stayed sicker than the year I was a parapro at a primary school. Kids are germy! That's when I started carrying around hand sanitizer. Cara, I read some real horror stories before my surgery too. When I had my phone consult with Dr. K, I asked him about complications and he mentioned five. I thought that they were all port revisions, tube punctures and/or tubes leaking. I don't remember him mentioning a removal, but you should feel free to ask him during your consult. There is the possibility of something going wrong with any surgery. But by going with an experienced surgeon, doing your research and resolving to follow his instructions to the letter, you are reducing your risk. That's all you can do.

I ran accross this today. I found it good information for those of us considering/waiting for WlS. Pouch Rules for Dummies INTRODUCTION: A common misunderstanding of gastric bypass surgery is that the pouch causes weight loss because it is so small, the patient eats less. Although that is true for the first six months, that is not how it works. Some doctors have assumed that poor weight loss in some patients is because they aren’t really trying to lose weight. The truth is it may be because they haven’t learned how to get the satisfied feeling of being full to last long enough. HYPOTHESIS OF POUCH FUNCTION: We have four educated guesses as to how the pouch works: 1. Weight loss occurs by actually slightly stretching the pouch with food at each meal or; 2. Weight loss occurs by keeping the pouch tiny through never ever overstuffing or; 3. Weight loss occurs until the pouch gets worn out and regular eating begins or; 4 Weight loss occurs with education on the use of the pouch. PUBLISHED DATA: How does the pouch make you feel full? The nerves tell the brain the pouch is distended and that cuts off hunger with a feeling of fullness. What is the fate of the pouch? Does it enlarge? If it does, is it because the operation was bad, or the patient is overstuffing themselves, or does the pouch actually re-grow in a healing attempt to get back to normal? For ten years, I had patients eat until full with cottage cheese every three months, and report the amount of cottage cheese they were able to eat before feeling full. This gave me an idea of the size of their pouch at three month intervals. I found there was a regular growth in the amount of intake of every single pouch. The average date the pouch stopped growing was two years. After the second year, all pouches stopped growing. Most pouches ended at 6 oz., with some as large at 9-10 ozs. We then compared the weight loss of people with the known pouch size of each person, to see if the pouch size made a difference. In comparing the large pouches to the small pouches, THERE WAS NO DIFFERENCE IN PERCENTAGE OF WEIGHT LOSS AMONG THE PATIENTS. This important fact essentially shows that it is NOT the size of the pouch but how it is used that makes weight loss maintenance possible. OBSERVATIONAL BASED MEDICINE: The information here is taken from surgeon’s “observations” as opposed to “blind” or “double blind” studies, but it IS based on 33 years of physician observation. Due to lack of insurance coverage for WLS, what originally seemed like a serious lack of patients to observe, turned into an advantage as I was able to follow my patients closely. The following are what I found to effect how the pouch works: 1. Getting a sense of fullness is the basis of successful WLS. 2. Success requires that a small pouch is created with a small outlet. 3. Regular meals larger than 1 ½ cups will result in eventual weight gain. 4. Using the thick, hard to stretch part of the stomach in making the pouch is important. 5. By lightly stretching the pouch with each meal, the pouch send signals to the brain that you need no more food. 6. Maintaining that feeling of fullness requires keeping the pouch stretched for awhile. 7. Almost all patients always feel full 24/7 for the first months, then that feeling disappears. 8. Incredible hunger will develop if there is no food or drink for eight hours. 9. After 1 year, heavier food makes the feeling of fullness last longer. 10. By drinking water as much as possible as fast as possible (“water loading”), the patient will get a feeling of fullness that lasts 15-25 minutes. 11. By eating “soft foods” patients will get hungry too soon and be hungry before their next meal, which can cause snacking, thus poor weight loss or weight gain. 12. The patients that follow “the rules of the pouch” lose their extra weight and keep it off. 13. The patients that lose too much weight can maintain their weight by doing the reverse of the “rules of the pouch.” HOW DO WE INTERPRET THESE OBSERVATIONS? POUCH SIZE: By following the “rules of the pouch”, it doesn’t matter what size the pouch ends up. The feeling of fullness with 1 ½ cups of food can be achieved. OUTLET SIZE: Regardless of the outlet size, liquidy foods empty faster than solid foods. High calorie liquids will create weight gain. EARLY PROFOUND SATIETY: Before six months, patients much sip water constantly to get in enough water each day, which causes them to always feel full. After six months, about 2/3 of the pouch has grown larger due to the natural healing process. At this time, the patient can drink 1 cup of water at a time. OPTIMUM MATURE POUCH: The pouch works best when the outlet is not too small or too large and the pouch itself holds about 1 ½ cups at a time. IDEAL MEAL PROCESS (rules of the pouch): 1. The patient must time meals five hours apart or the patient will get too hungry in between. 2. The patient needs to eat finely cut meat and raw or slightly cooked veggies with each meal. 3. The patient must eat the entire meal in 5-15 minutes. A 30-45 minute meal will cause failure. 4. No liquids for 1 ½ hours to 2 hours after each meal. 5. After 1 ½ to 2 hours, begin sipping water and over the next three hours slowly increase water intake. 6. 3 hours after last meal, begin drinking LOTS of water/fluids. 7. 15 minutes before the next meal, drink as much as possible as fast as possible. This is called “water loading.” IF YOU HAVEN’T BEEN DRINKING OVER THE LAST FEW HOURS, THIS ‘WATER LOADING’ WILL NOT WORK. 8. You can water load at any time 2-3 hours before your next meal if you get hungry, which will cause a strong feeling of fullness. THE MANAGEMENT OF PATIENT TEACHING AND TRAINING: You must provide information to the patient pre-operatively regarding the fact that the pouch is only a tool: a tool is something that is used to perform a task but is useless if left on a shelf unused. Practice working with a tool makes the tool more effective. NECESSITY FOR LONG TERM FOLLOW-UP: Trying to practice the “rules of the pouch” before six to 12 months is a waste. Learning how to delay hunger if the patient is never hungry just doesn’t work. The real work of learning the “rules of the pouch” begins after healing has caused hunger to return. PREVENTION OF VOMITING: Vomiting should be prevented as much as possible. Right after surgery, the patient should sip out of 1 oz cups and only 1/3 of that cup at a time until the patient learns the size of his/her pouch to avoid being sick. It is extremely difficult to learn to deal with a small pouch. For the first 6 months, the patient’s mouth will literally be bigger than his/her stomach, which does not exist in any living animal on earth. In the first six weeks the patient should slowly transfer from a liquid diet to a blenderized or soft food diet only, to reduce the chance of vomiting. Vomiting will occur only after eating of solid foods begins. Rice, pasta, granola, etc. will swell in time and overload the pouch, which will cause vomiting. If the patient is having trouble with vomiting, he/she needs to get 1 oz cups and literally eat 1 oz of food at a time and wait a few minutes before eating another 1 oz of food. Stop when “comfortably satisfied,” until the patient learns the size of his/her pouch. SIX WEEKS After six weeks, the patient can move from soft foods to heavy solids. At this time, they should use three or more different types of foods at each sitting. Each bite should be no larger than the size of a pinkie fingernail bed. The patient should choose a different food with each bite to prevent the same solids from lumping together. No liquids 15 minutes before or 1 ½ hours after meals. REASSURANCE OF ADEQUATE NUTRITION By taking vitamins everyday, the patient has no reason to worry about getting enough nutrition. Focus should be on proteins and vegetables at each meal. MEAL SKIPPING Regardless of lack of hunger, patient should eat three meals a day. In the beginning, one half or more of each meal should be protein, until the patient can eat at least two oz of protein at each meal. ARTIFICIAL SWEETENERS In our study, we noticed some patients had intense hunger cravings which stopped when they eliminated artificial sweeteners from their diets. AVOIDING ABSOLUTES Rules are made to be broken. No biggie if the patient drinks with one meal – as long as the patient knows he/she is breaking a rule and will get hungry early. Also if the patient pigs out at a party – that’s OK because before surgery, the patient would have pigged on 3000 to 5000 calories and with the pouch, the patient can only pig on 600-1000 calories max. The patient needs to just get back to the rules and not beat him/herself up. THREE MONTHS At three months, the patient needs to become aware of the calories per gram of different foods to be aware of “the cost” of each gram. (cheddar cheese is 16 cal/gram; peanut butter is 24 cals/gram). As soon as hunger returns between three to six months, begin water loading procedures. THREE PRINCIPLES FOR GAINING AND MAINTAINING SATIETY 1. Fill pouch full quickly at each meal. 2. Stay full by slowing the emptying of the pouch. (Eat solids. No liquids 15 minutes before and none until 1 ½ hours after the meal). A scientific test showed that a meal of egg/toast/milk had almost all emptied out of the pouch after 45 minutes. Without milk, just egg and toast, more than ½ of the meal still remained in the pouch after 1 ½ hours. 3. Protein, protein, protein. Three meals a day. No high calorie liquids. FLUID LOADING Fluid loading is drinking water/liquids as quickly as possible to fill the pouch which provides the feeling of fullness for about 15 to 25 minutes. The patient needs to gulp about 80% of his/her maximum amount of liquid in 15 to 30 SECONDS. Then just take swallows until fullness is reached. The patient will quickly learn his/her maximum tolerance, which is usually between 8-12 oz. Fluid loading works because the roux limb of the intestine swells up, contracting and backing up any future food to come into the pouch. The pouch is very sensitive to this and the feeling of fullness will last much longer than the reality of how long the pouch was actually full. Fluid load before each meal to prevent thirst after the meal as well as to create that feeling of fullness whenever suddenly hungry before meal time. POST PRANDIAL THIRST It is important that the patient be filled with water before his/her next meal as the meal will come with salt and will cause thirst afterwards. Being too thirsty, just like being too hungry will make a patient nauseous. While the pouch is still real small, it won’t make sense to the patient to do this because salt intake will be low, but it is a good habit to get into because it will make all the difference once the pouch begins to regrow. URGENCY The first six months is the fastest, easiest time to lose weight. By the end of the six months, 2/3 of the regrowth of the pouch will have been done. That means that each present day, after surgery you will be satisfied with less calories than you will the very next day. Another way to put it is that every day that you are healing, you will be able to eat more. So exercise as much as you can during that first six months as you will never be able to lose weight as fast as you can during this time. SIX MONTHS Around this time, our patients begin to get hungry between meals. THEY NEED TO BATTLE THE EXTRA SALT INTAKE WITH DRINKING LOTS OF FLUIDS IN THE TWO TO THREE HOURS BEFORE THEIR NEXT MEAL. Their pouch needs to be well watered before they do the last gulping of water as fast as possible to fill the pouch 15 minutes before they eat. INTAKE INFORMATION SHEET AS A TEACHING TOOL I have found that having the patients fill out a quiz every time they visit reminds them of the rules of the pouch and helps to get them “back on track.” Most patients have no problems with the rules, some patients really struggle to follow them and need a lot of support to “get it”, and a small percentage never quite understand these rules, even though they are quite intelligent people. HONEYMOON SYNDROME The lack of hunger and quick weight loss patients have in the first six months sometimes leads them to think they don’t need to exercise as much and can eat treats and extra calories as they still lose weight anyway. We call this the “honeymoon syndrome” and they need to be counseled that this is the only time they will lose this much weight this fast and this easy and not to waste it by losing less than they actually could. If the patient’s weight loss slows in the first six months, remind them of the rules of water intake and encourage them to increase their exercise and drink more water. You can compare their weight loss to a graph showing the average drop of weight if it will help them to get back on track. EXERCISE In addition to exercise helping to increase the weight loss, it is important for the patient to understand that exercise is a natural antidepressant and will help them from falling into a depression cycle. In addition, exercise jacks up their metabolic rate during a time when their metabolism after the shock of surgery tends to want to slow down. THE IDEAL MEAL FOR WEIGHT LOSS The ideal meal is one that is made up of the following: ½ of your meal to be low fat protein, ¼ of your meal low starch vegetables and ¼ of your meal solid fruits. This type of meal will stay in your pouch a long time and is good for your health. VOLUME VS. CALORIES The gastric bypass patient needs to be aware of the length of time it takes to digest different foods and to focus on those that take up the most space and take time to digest so as to stay in the pouch the longest, don’t worry about calories. This is the easiest way to “count your calories.” For example, a regular stomach person could gag down two whole sticks of butter at one sitting and be starved all day long, although they more than have enough calories for the day. But you take the same amount of calories in vegetables, and that same person simply would not be able to eat that much food at three sittings – it would stuff them way too much. ISSUES FOR LONG TERM WEIGHT MAINTENANCE Although everything stated in this report deals with the first year after surgery, it should be a lifestyle that will benefit the gastric bypass patient for years to come, and help keep the extra weight off. COUNTER-INTUITIVENESS OF FLUID MANAGEMENT I admit that avoiding fluids at meal time and then pushing hard to drink fluids between meals is against everything normal in nature and not a natural thing to be doing. Regardless of that fact, it is the best way to stay full the longest between meals and not accidentally create a “soup” in the stomach that is easily digested. SUPPORT GROUPS It is natural for quite a few people to use the rules of the pouch and then to tire of it and stop going by the rules. Others “get it” and adhere to the rules as a way of life to avoid ever regaining extra weight. Having a support group makes all the difference to help those that go astray to be reminded of the importance of the rules of the pouch and to get back on track and keep that extra weight off. Support groups create a “peer pressure” to stick to the rules that the staff at the physician’s office simply can’t create. TEETER TOTTER EFFECT Think of a teeter totter suspended in mid air in front of you. Now on the left end is exercise that you do and the right end is the foods that you eat. The more exercise you do on the left, the less you need to worry about the amount of foods you eat on the right. In exact reverse, the more you worry about the foods you eat and keep it healthy on the right, the less exercise you need on the left. Now if you don’t concern yourself with either side, the higher the teeter totter goes, which is your weight. The more you focus on one side or the other, or even both sides of the teeter totter, the lower it goes, and the less you weigh. TOO MUCH WEIGHT LOSS I have found that about 15% of the patients which exercise well and had between 100 to 150 lbs to lose, begin to lose way too much weight. I encourage them to keep up the exercise (which is great for their health) and to essentially “break the rules” of the pouch. Drink with meals so they can eat snacks between without feeling full and increase their fat content as well take a longer time to eat at meals, thus taking in more calories. A small but significant amount of gastric bypass patients actually go underweight because they have experienced (as all of our patients have experienced) the ravenous hunger after being on a diet with an out of control appetite once the diet is broken. They are afraid of eating again. They don’t “get” that this situation is literally, physically different and that they can control their appetite this time by using the rules of the pouch to eliminate hunger. BARIATRIC MEDICINE A much more common problem is patients who after a year or two plateau at a level above their goal weight and don’t lose as much weight as they want. Be careful that they are not given the “regular” advice given to any average overweight individual. Several small meals or skipping a meal with a liquid protein substitute is not the way to go for gastric bypass patients. They must follow the rules, fill themselves quickly with hard to digest foods, water load between, increase their exercise and the weight should come off much easier than with regular people diets. SUMMARY 1. The patient needs to understand how the new pouch physically works. 2. The patient needs to be able to evaluate their use of the tool, compare it to the ideal and see where they need to make changes. 3. Instruct your patient in all ways (through their eyes with visual aids, ears with lectures and emotions with stories and feelings) not only on how but why they need to learn to use their pouch. The goal is for the patient to become an expert on how to use the pouch. EVALUATION FOR WEIGHT LOSS FAILURE The first thing that needs to be ruled out in patients who regain their weight is how the pouch is set up. 1. the staple line needs to be intact; 2. same with the outlet and; 3. the pouch is reasonably small. 1) Use thick barium to confirm the staple line is intact. If it isn’t, then the food will go into the large stomach, from there into the intestines and the patient will be hungry all the time. Check for a little ulcer at the staple line. A tiny ulcer may occur with no real opening at the line, which can be dealt with as you would any ulcer. Sometimes, though, the ulcer is there because of a break in the staple line. This will cause pain for the patient after the patient has eaten because the food rubs the little opening of the ulcer. If there is a tiny opening at the staple line, then a reoperation must be done to actually separate the pouch and the stomach completely and seal each shut. 2) If the outlet is smaller than 7-8 mill, the patient will have problems eating solid foods and will little by little begin eating only easy-to-digest foods, which we call “soft calorie syndrome.” This causes frequent hunger and grazing, which leads to weight regain. 3) To assess pouch volume, an upper GI doesn’t work as it is a liquid. The cottage cheese test is useful – eating as much cottage cheese as possible in five to 15 minutes to find out how much food the pouch will hold. It shouldn’t be able to hold more than 1 ½ cups in 5 – 15 minutes of quick eating. If everything is intact then there are four problems that it may be: 1) The patient has never been taught the rules; 2) The patient is depressed; 3) The patient has a loss of peer support and eventual forgetting of rules, or 4) The patient simply refuses to follow the rules. LACK OF TEACHING An excellent example is a female patient who is 62 years old. She had the operation when she was 47 years old. She had a total regain of her weight. She stated that she had not seen her surgeon after the six week follow up 15 years ago. She never knew of the rules of the pouch. She had initially lost 50 lbs and then with a commercial weight program lost another 40 lbs. After that, she yo-yoed up and down, each time gaining a little more back. She then developed a disease (with no connection to bariatric surgery) which weakened her muscles, at which time she gained all of her weight back. At the time she came to me, she was treated for her disease, which helped her to begin walking one mile per day. I checked her pouch with barium and the cottage cheese test which showed the pouch to be a small size and that there was no leakage. She was then given the rules of the pouch. She has begun an impressive and continuing weight loss, and is not focused on food as she was, and feeling the best she has felt since the first months after her operation 15 years ago. DEPRESSION Depression is a strong force for stopping weight loss or causing weight gain. A small number of patients, who do well at the beginning, disappear for awhile only to return having gained a lot of weight. It seems that they almost on purpose do exactly opposite of everything they have learned about their pouch: they graze during the day, drink high calorie beverages, drink with meals and stop exercising, even though they know exercise helps stop depression. A 46 year-old woman, one year out of her surgery had been doing fine when her life was turned upside down with divorce and severe teenager behavior problems. Her weight skyrocketed. Once she got her depression under control and began refocusing on the rules of the pouch, added a little exercise, the weight came off quickly. If your patient begins weight gain due to depression, get him/her into counseling quickly. Encourage your patient to refocus on the pouch rules and try to add a little exercise every day. Reassure your patient that he/she did not ruin the pouch, that it is still there, waiting to be used to help with weight control. When they are ready the pouch can be used once again to lose weight without being hungry. EROSION OF THE USE OF PRINCIPLES: Some patients who are compliant, who are not depressed and have intact pouches, will begin to gain weight. These patients are struggling with their weight, have usually stopped connecting with their support groups, and have begun living their “new” life surrounded by those who have not had bariatric surgery. Everything around them encourages them to live life “normal” like their new peers: they begin taking little sips with their meals, and eating quick and easy-to-eat foods. The patient will not usually call their physician’s office because they KNOW what they are doing is wrong and KNOW that they just need to get back on track. Even if you offer “refresher courses” for your patients on a yearly basis, they may not attend because they KNOW what the course is going to say, they know the rules and how they are breaking them. You need to identify these patients and somehow get them back into your office or back to interacting with their support group again. Once these patients return to their support group, and keep in contact with their WLS peers, it makes it much easier to return to the rules of the pouch and get their weight under control once again. TRUE NON-COMPLIANCE: The most difficult problem is a patient who is truly non-compliant. This patient usually leaves your care, complains that there is no ‘connection’ between your staff and themselves and that they were not given the time and attention they needed. Most of the time, it is depression underlying the non-compliance that causes this attitude. A truly non-compliant patient will usually end up with revisions and/or reversal of the surgery due to weight gain or complications. This patient is usually quite resistant to counseling. There is not a whole lot that can be done for these patients as they will find a reason to be unhappy with their situation. It is easier to identify these patients BEFORE surgery than to help them afterwards, although I really haven’t figured out how to do that yet… Besides having a psychological exam done before surgery, there is no real way to find them before surgery and I usually tend toward the side of offering patients the surgery with education in hopes they can live a good and healthy life.

oh BBK, i'd be so pissed .. sorry that happened. since it was his decision, the revision (and all related costs) should be waived or charged to him... i really need to look into the powdered Peanut Butter.... i love the stuff but havent eaten it in ages due to the fat content..