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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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Your diet composition and how frequently you eat determines how hungry you are for the most part. If I eat CRAP and carby stuff? I want to eat every 2 hours. It's hell for 2-4days to break that cycle. If I have a weekend of grazing and "treat" type foods with higher carb items and any alcohol? I want to eat like a beast for 2-4 days after. But if I eat my plan, work my plan, and do what I know to be true for my body and lifestyle and health status? I have "appropriate" hunger. At this point in your recovery, you should be able to make 3 hours between meals IMHO or longer. Missing a meal is not an emergency for me anymore--now that the initial phases of healing are finished. I regularly go 4-6 hours between meals or longer and I do IF for 16-20 hours on selected days without a great deal of hunger. But the more and more often I eat of very deeply pleasurable foods? The MORE of them I want to eat.

Two and a half years ago I embarked on my weight loss surgery journey. The six months that I needed to complete all of my pre requistes went by pretty fast. A test for this, a test for that, conferring with this person, etc etc. ( You guys know what I mean) It all culminated with my gastric sleeve surgery in August 2017. Fast forward two years and I lost 63 lbs and gained better health. Long gone are the multiple medications I had to take in order to survive. The Meds helped with my heart condition, diabetes, high blood pressure , gout , and other assorted chronic conditions. Unfortunately, the same medications that helped me with those chronic conditions were wrecking havoc on my liver and kidneys. The panacea to help with my chronic conditions and save my vital organs was to lose weight, adopt a healthier lifestyle and maintain the weight loss. . When I say lose weight I meant a good amount of it, 20 lbs was not going to cut it this time. I have been on maintenance for 17 months. For me, it's a struggle everyday. I attend Over Eaters Anonymous meetings and meet with a therapist once a week. I am trying my best to maintain my new found health as I know the insurance company will not give me a do over. My wife who has monitored my journey and has a few chronic conditions herself has recently had her gastric sleeve surgery. As we do with so many other things in life we are doing this together. A friend of mine who is quite over weight and suffers from chronic conditions also had gastric sleeve surgery and he is experiencing a rapid weight loss. Hey looks very different. A very close friend and his wife also seeing my result with WLS both recently has gastric sleeve surgery. The wife is experiencing a rapid weight loss the husband is losing slow and sure. Prior to their surgeries I counseled them on the pitfalls of relying on surgery alone for long term success. I know three people that had WLS in the past and all three told me that they gained all the weight back and then some. Surprisingly all three work in my various doctors offices. These people are close to medical advice and two are medical professionals. I told my family and friends about these three ( I got permission to tell their stories but I left out the names) and warned them against having the surgery if they couldn't commit to a new lifestyle. They only had one shot at it as insurance would probably not pay again. It was better to wait to get WLS than to rush into it unprepared. So far all four are doing well. I speak to my friends at least twice a week to lend support and guidance. This also helps me to keep on track as I find that these conversations help reinforce my good habits as well. My couple friends suggested that we should get together as we have talked on the phone but haven't seen each other in person for a few months. They recommended we meet at a restaurant we frequented in the past and indulge in appetizers. I asked them why are we planning to meet in a restaurant? That would be like asking recovering alcoholics to meet in a bar for sodas. We need to stop the cycle of using food as a social event. We need to think of food as fuel for the body not as a diversion to socialize. They both are only out six months from WLS and they should rethink their relationship with food. In the end we met at the Botanical Gardens for a leisurely stroll among the flora. I'm so glad that I had the experience of WLS and that I am able help others achieve better health with theirs. For me, I still have a long road of recovery ahead of me and I take it one day at a time. I stopped eating processed foods, eat mindfully and now instead of living to eat, I eat to live. Good health to everyone.

My daughter is one year out of gastric sleeve surgery. She has done very well but in the last couple weeks she has been experiencing very high liver enzyme’s and Billiruben in her urine. She is in the hospital right now and they have ruled out Hepatitis. They do not seem to be paying much attention to the fact that she has had gastric sleeve. She only drinks alcohol socially. And she is only 24.Has anyone heard of this complication a year after surgery or more?

Wow! Hard core dude. LOL. Great it's worked for you and your bro. Congrats on your weight loss. I do agree that from my viewpoint, you have to be willing to say "screw food" -- at least in the WLM--in order to lose the quickest and get to goal without potentially setting yourself up for stalling out too soon and losing focus. I do think many of us have to completely change and break up with the foods that contributed to our poor eating behaviors. Otherwise, like alcoholics, we run the risk of recidivism. The beauty of the initial weeks out from surgery and the honeymoon period is that it presents an opportunity to break up with old habits and almost painlessly build new healthy habits and learn new food ways of eating. Thanks for showing us your plan!!! p.s. I never really had ANY post op pain or pain in refeeding...

@ms.sss Wow congrats on your surprise vacation. Get bikini fit before you go, You deserve to indulge and enjoy. You know yourself best. Try to be ok with a small weight gain. You can trust yourself to work it off after you get back. I am just checking in after a short vacation and family wedding. A fantastic time was had. I was 130 at the start of vacation and I’m now 143. A bit over my ten-pound bounce range. Clothing is tight. My body is not used to the craptacular food and alcohol choices over the last week. I feel sluggish and not myself. I appreciate how good I feel when I eat on plan. Looking forward to getting my weight back in range.

I haven't had any form of alcohol in several years. It doesn't fit with my lifestyle or choices anymore. I'm 5 years post VSG and had to really overhaul my entire lifestyle. even after surgery and I lost my weight, I got some sobering health news that made me have to tighten up my eating even more. I stick to sugar free iced coffee when I'm out and about, and have some Zevia-flat- for a treat.

Ok, so please note, I do not advocate drinking alcohol after WLS. Bad things happen to good bari peeps, mmmmkay? Having said that, if you have a lot of stress in your life, this whacked crash diet from the 70's Vogue, sounds compelling on the surface! bahahaha!

Wait patiently and work on lifestyle modifications. Try getting some walking in, start eliminating things from your diet that you won't be able to have after surgery. I found that this was very helpful. Recovery is hard enough without going through withdrawal from cravings. Give up the sugar, simple starches, caffeine, soda, alcohol. If dieting worked for you, you would have already lost the weight and kept it off by now. Like many of us, you have probably lost and regained many times. All that does is wreck your metabolism and short circuit the stomach-brain transmissions, making permanent weight loss nigh unto impossible. The time will past quickly, with holidays right around the corner, and starting a new job. Hang in there!

Be sure to take it easy for the new years celebrations no alcohol etc preop

My experience with all inclusives is similar to @ms.sss's. The food isn't good enough to be all that compelling. But the alcohol on the other hand ....

True, if you can't control yourself. I was a weekend drinker but as soon as I started my first nutritional session I stopped cold turkey. It's not worth my health. I plan to have wine March 15th, my BIRTHDAY. So if anyone is a alcoholic or borderline - STAY AWAY. I do understand & respect your answer : )

I eat fairly simply. Never been a spicy food person so no loss there. The only carb I knowingly eat is rolled oats. I can eat fish, all meats, eggs & cheeses. My tastebuds still are not fond of many vegetables & fruit I used to love though. The only takeaway food i’ve tried is Chinese chicken & cashews (without the cashews). As I can only eat small amounts, I focus on protein and eat little or no vegetables or salad - three/four spoons of protein (half a sausage, a small lamb cutlet, small chicken leg) & a small cauliflower floret & i’m done. Takes me three days to eat two scrambled eggs. I eat slowly & mindfully. If i’m stressed (like worrying about what I can eat when dining out) my body shuts down & I can eat even less. (I’ve had to calm several concerned wait staff stressing everything tasted delicious & the reason i’ve barely touched my meal is just me.) I find it hard to get my fluids in each day. Alcohol is an occasional treat now - I can nurse a gin & tonic for hours. Tolerated my first glass of champagne last week. Yay! Only vomited food once. I just wish the gurgling would stop and the hair loss. Listen to your body. Find what works for you. Everyone’s experience is different. Yes, you will have to change your diet & find healthier foods to eat. But this is a new and better world. Enjoy!

Thanks guys. lol, I’m the queen of disorganization myself, but Anna is super kind and I’m always such a big fan of hers. November feel free to chime in with any questions or concerns, we’re more than happy to help out. Research and prep are KEY to success, and as a type A control freak, I definitely understand. Anna, I’m so glad your hair stopped falling out! Honestly I don’t know if mine has stopped, but at least it doesn’t seem to be falling out more. I’ve got a cut and color scheduled for mid-next month for a bday present, and I haven’t had new color since about 2 weeks after surgery. Can’t wait. Girl you’ve GOT to keep drinking that water. So far I’ve avoided the dread UTI, but I think I came close back in July when we took that NOLA trip and I drank about 1500 calories a day in alcohol. Usually I’m uber-hydrated at 80 plus ounces water daily, so it was a radical change. I can’t believe this, but I’m about 7 pounds away from goal and it’s probably going to happen by my 9 month surgiversary. TBH, I knew I’d lose weight from WLS, but never would’ve imagined I’d ever truly hit goal. How many of you guys have an actual plan for maintenance? I’ve discovered that I really kind of don’t have a plan and that’s a bit scary for me.

OMG, I forgot to respond to everyone's replies. I actually get this..like every 2 to 4 weeks it seems. The first 2 times was before I had healed very much (I'm...7 weeks out now?)...and I got so dehydrated I was sent to hospital for a long duration of IV fluids. They also gave me some meds for abdominal pain/cramping (I had already taken the 2 different meds my surgeon had prescribed for this and he prescribed Tramadol as well, but Tramadol does nothing for me). When the 'meds' I had at home were not enough to suffice and after hours of enduring the agony, I actually did call dr both times. That 1st hospital visit also gave me some type of pain relief but I have no clue what it was. It was not what I had on hand, nor was it a heavy duty narcotic. The 2nd time I had this kind of pain I was sent to another facility to drink soapy water (I was only a few weeks out and it was one of worst things I've ever had to try to drink, esp with being not even 1 month past operation. Scan showed no leaks, etc. The 3rd time, I was told to go back to hospital I had scan at. Was kept overnight. Was in awful pain. Scan done again and only thing they could see this time was that my esophagus tended to spasm which answered question of why I felt my throat and 'restriction' were locking down sometimes after even a small mouthful of water. Only thing the hospital offered me for pain relief was IV tramadol. I didn't even pay attention as I was so completely miserable..I just noticed that I had NO pain relief during the 15 hrs I was @ hospital, unlike 1st one i went to where they gave me something that helped. THUS, I have resolved to NOT go back to a hospital I do not let my dr know any more when I have these..episodes? It seems the ONLY test that can be run during these horrid events is just the soap drink/check your GI tract/pouch? No thank you. If I am going to spend almost a full day ((or what ends up being a full day out of commission), with no way to even take the edge off the pain..then I'll stay home and keep trying to get through it. I don't know if it is the dang opioid crisis or what, but my prescription history shows i do not take ANY pain pills as a general rule. They just are usually not worth it. They could check previous hospitalizations and see that 90% of the time I turn down heavy duty pain meds and opt for 'less powerful' pain meds (tylenol, etc. and no, not tylenol with anything added). That is why 10 days ago...on what I now see was the 4th time to have the exact same symptoms I just posted here. I should have given the backstory.... My fingers are crossed that I never have another episode again! If i do though, I'm just staying here. It hurts enough that if I could drink alcohol and IF that even helped anything, I MAYBE would do so...but that is not my preferred way to handle things.

I think this post of FluffyChix's is the crux of the matter for me. It is all about knowing myself. Like her, I knew what sort of behaviour resulted in obesity, and like her, I need to be accountable for it. For me, my Achilles heel was alcohol (2-3 glasses of red wine a night) and portions of healthy food that were just too large. Now I've cut out the alcohol (apart from special occasions) and got the portion size right, I feel I'm in control. But I recognise that different people have to do different things to be in control.

Okay so after a rather decadent weekend (mostly with alcohol, not food) I’m hitting it now with a 24 hr fast. At 6:30 We finished up a dinner of chicken and salad and I even found some passable avocado to add to the salad for some extra healthy fat and calories. I’m so stuffed right now that I don’t feel like eating for 3 days, lol. Plan is to get up early for Pilates, spend some time organizing some clothes to do a sell-back before going to work at 1pm, then finding a way to break my fast tomorrow night at work after 6pm. I’m going to do an 8 ounce beef bone broth cup with some sea salt before I go to work. I’ll try to remember to post when I get off work tomorrow night and let y’all know how it went

Oh thank God it’s not just me. I’ve never been pregnant, but it feels like a hormonal craving. I find myself with the frig door open, eyeing the pickle jar whilst looking around to make sure nobody’s watching my weird obsession with pickle juice! I’m going to look for the drink! I can make my own alcohol-free cocktail!! Thanks so much!! P.s. I eat the pickles too, sometimes. That crunch & burst of pickle juice in my mouth - Nirvana! 😂😉👍🏼

The best: Getting my life back!!! I feel 20 years younger and am doing things now that I haven't been able to do for decades. Rode 15 miles on my bike today and felt great! Hiking hills, riding my mule, climbing stairs, swimming (in a size 10 suit!!!), getting down and up off the floor, no more sleep apnea, no problems with asthma or reflux, no fungal infections in my skin folds this summer, no joint pain, normal BP and blood sugars (ie: no more metabolic syndrome!), wearing cute clothes, feeling "normal" in a crowd, more confidence, not having to size up the furniture in a room to decide which I will fit into, the list just goes on and on. I took a "Biological Age" test, and I am 16 years younger than my stated age! Hurray!!! The worst: Can't think of any. This is one of the best decisions I have ever made for myself. I LOVE my new active lifestyle and lifelong way of eating. Yes, there can be temptations, but they get easier and easier to deal with as you see the benefits of healthy choices. Sugar and desserts have no appeal at all any more. Neither do processed foods, coffee, soda, or alcohol. I do not even see those as sacrifices - not when I get to eat so many other healthy things. I guess one thing might be that when I go out to eat, I can only finish about 1/4 of the meal. I take the rest home, but the left overs are really not that great past a day, so I end up giving the rest to the chickens. So that's a waste of money. I am learning to order off the appetizer menu and to not let my eyes get bigger than my stomach. It's a process. Another thing might be that I feel a bit self conscious about my face, which I think looks old and wrinkly now. Others tell me differently and that I look younger, but I just don't see it that way. I am trying to be more out going and cheerful so that the wrinkles look more like smile lines than grumpy lines. That's just a matter of building confidence and learning to accept a great new body, but one that looks a little funny in places.

Well I’m assuming that you’re referring to healthy low-carb, high Protein food because otherwise why would a person even consider WLS if they don’t plan to radically change their diet, right? That being said, I’ve tried a few things in my 7 months that aren’t truly on the “approved” list. Mostly alcohol. Anytime I have alcohol it goes and stays down just fine, but the price I pay is slowed weight loss for a few days so I truly pick and choose those times carefully. Went to a wedding July 4th and had 3 glasses wine, some bbq brisket, smoked chicken , Mac and cheese, cole slaw and a couple bites of a piece of bread, and half a slice of wedding cake. Quite honestly everything except the brisket and smoked chicken (that I ate without the sauce) were the worst things I ate. All the carb-ey stuff tasted kinda weird and gross. The cake was just “okay” and people everywhere were raving about how delicious it was. *shrug* The wine was simply awesome and I’m kind of sad in a way that I haven’t lost my complete and utter love for wine. OTOH, at least I still do have this every now and again indulgence I can turn to. Okay, so let’s talk “healthier” options. One food I used to LOVE was eggs. Any kind cooked any way. I loved me some eggs. Now I can’t really even tolerate part of a boiled egg on salad bc eggs give me horrible cramping. Also mayo. Cannot have even a smidge of mayo or insta-cramps. Some would think maybe my gall bladder is acting up, but so far that’s been ruled out. I used to be (and still am) a complete salad mix freak. Thank goodness I can still put away a cup or more of leafy greens without difficulty. Some people can’t so I’m thankful. In fact, I’d be willing to bet over half my carbs daily (which isn’t much) comes from different salad greens.

Alcohol and NSAIDS are big no-no's. The acid in coffee can cause problems, as well.

That is very encouraging! I also have no problem living without soda or alcohol, I have heard soda can cause problems but I can do without it. I had not heard anything about straws, I use them all the time, hmm......I hope I can keep doing so!

I am very happy with my bypass. My GERD is gone, which has relieved my asthma as well. I started exercising right away, gradually adding elements of cardio, weights, stretching. I have more muscle mass now than before surgery. I have also entered a triathon in Oct and a bicycle event in November. I have so much energy now and feel 20 years younger! My only issue with malabsorption is with fat. If I eat too much it will come out in my stools. All of my 6 month vitamin levels were great, but I do take my vitamins faithfully, which I think is a small price to pay in exchange for the life I have now. My only other issue is getting enough calories in now, to keep up with my training schedule. My pouch limits intake, so I am having to eat more frequently and starting to add more healthy carbs back into the menu. All in all, I couldn't ask for a better outcome. I respect anyone's decision about which surgery to have, but it seems quite a few folks with the sleeve end up getting revised to bypass. I was also fixed on the sleeve until I understood the advantages of bypass with helping GERD and since that was an issue for me, it became a no brainer. I also like the fact that dumping can occur with sugar intake, when bypass is chosen. That is a great detriment for me to avoid sugar. Sugar is poison. I want no part of it, and my tummy agrees! No brainer there. I am also commited to taking care of my pouch and all the connections as well as possible. I work in the GI department of our hospital and I have seen firsthand the damage that can be done to WLS sites - ulcers and erosions beyond horror. So no alcohol, coffee, or NSAIDs for me. Those are my personal choices - again, a small price to pay for the life I have now. Best wishes in your journey!

Congrats on your appointment Maureen! I'm 3 months post op & I don't think there's anything I can't eat. I haven't tried bread, other than low carb wraps & those are absolutely fine. Honesty I went into this thinking I was giving up like, idk all sorts of things. I really thought, I'd never be able to eat them again. And even 3 months out I'm realizing that's not going to be true for me. Nothing has made me sick. This has all been super smooth sailing for me. That said, it means it's really up to me to say NO to all sorts of things. If that makes any sense? Like I sorta thought if I ate sugar or something, I'd be horribly sick like many of the members of this site. I haven't tested sugar much, but I had a tablespoon or two of creme brûlée at one point, I was fine. I've had halo top a couple times, I was fine. So far, I've had chicken, steak, ground beef, turkey sausage. All has been absolutely fine. Oh pizza! I have had pizza since surgery. Probably 10 weeks post op? I had a serving about the size of a slice of bread & I was fine. Is it something I'm purposely eating on a regular basis, no. I was at a thing & that was what was served. I haven't had alcohol or soda since surgery. Neither of them means anything to me so it's no hardship on me not to have them. I drink a lot of coffee & my doctor is fine with it. I also use straws - he's fine with that as well. You'll find a lot of varying opinions about that here. All in all, I feel exactly the same as I did before - in a good way. I don't really feel like much has changed for me except my stomach is much smaller & I eat much less. It's still up to me to make smart choices, but it's MUCH easier for me to do that with a stomach this small.

You have lost 36 lbs in 2 months?! Congratulations!!! I’m obsessed with reading and watching everything I can. I will admit my eating lately isn’t perfect and I’m working on fixing that. I did quite well in the first month but this past month not so much. I have major some major changes that I have stuck to...quit coffee, no more drinking alcohol (was a social drinker) and I have introduced protein shakes into my life. I am scheduled for rny on 10/15. I’m only down 5 from my first appointment in July. It was 9... You are doing GREAT!