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I think what you mix alcohol with also makes a difference. About 3 1/2 months out I tried a prickly pear margarita when we were on vacation in Santa Fe. Literally one sip and I felt hot and nauseated so I put it aside. We then ate and I tried again after 30 minutes with the same result. Now, I only drink tequila over ice, bourbon and water or vodka martinis and I have no problems. It does affect my ability to lose though..... I was a daily drinker before surgery and pretty much back to that at this point.

There are many ways to answer that question. For one thing, to some people sugar really is an addiction in the exact same way drugs or alcohol is. I am one of those people. I couldnt go a day without sugar and pretty much after every meal I would crave sugar like crazy. I remember one terrible Christmas we made dozens of cookies and I ate those damn cookies like they were crack for the next 3 weeks. I just kept thinking "this has to stop". So at that point I was definitely not able to moderate it. Now, 9 months post surgery I have completely changed my life. I have changed my coping mechanisms, I havent had any deserts and I work out regularly. I am debating the idea of having tiny amounts of sweets. Have I changed enough? Have I come far enough to be able to moderate? I honestly dont know.

Hello! This is my first time posting, I have been lurking for a while. I hope I am posing in the correct section!! I am from Canada, and was referred to the Bariatric Program in my city. I know that the USA and Canadian programs are similar in terms of requiring time with a dietitian, psychologist, internal medicine doctor etc. In April, I was booked for my first class in June. As a smoker (now ex-smoker!) I planned to (and quit) a few days before the orientation class. In the orientation class, immediately we are informed that being in the program or class isn't a guarantee of surgery (which is completely acceptable!), it is posted everywhere, and we are reminded of it pretty much all the time. I had an appointment with the Nurse case manager in August. She was great. In each appointment, you book your next appointment with another discipline you need to see throughout the program. I was then booked for a nutrition basics class for the end of August, then with the dietitian in September. The nutrition class I didn't find particularly useful (personally), as the things that we covered, I was already practicing. I was excited that the dietitian wasn't the type to roll in there and tell everyone they had to eat a certain diet. In the class (there was about 20-25 attending) she had said that they started doing the nutrition basics class because they felt that they often had to go over basics with so many people...they thought one class for everyone for the basics, and then when you meet with your dietitian, it is more individualized, and targeted to your needs. I was very excited about this, and it turned out the dietitian that was teaching the class, was who I was booked with in September. Then I rolled into the appointment in September (the day before my vacation - a cruise) for my first appointment with the RD. I feel like we immediately started off on the wrong foot. I had blood tests done (as requested) and I don't think she liked them. Everything on the blood tests were fine. Whenever I get tested for my white blood cells they come back 'slightly high', and it's been like that for years and I chalk it up to obesity, knee arthritis and the steroids I take for asthma. My family doctor is not concerned. The other thing was my triglycerides were boderline high (the rest of my cholesterol is good), and I have spoken with my doc about that and he is not concerned. She didn't seem to like that I wasn't running to my doctor about my white blood cell count. I felt like she was snippy about the triglycerides, even though my doc wasn't concerned. She looked at my food tracking (every day religiously for 6 weeks), and looked at one day. I eat 1 banana and 1 apple everyday during the work week. She started telling me about substituting berries instead of a banana. She also suggested that I walk around the buffet a few times on the cruise ship before deciding what to eat. When she asked how much wine I was going to drink on vacation (I stopped all alcohol for over a month at this point), and I said "Maybe 1 glass per day at dinner...?" that was the WRONG answer...and told me to try again. So I said...I guess 1 glass every 3 days....? Then she suggested I use smaller plates to cut my portion sizes. I left there...and my poor husband...I came home in a flurry of tears, and frustration. I didn't ask how to reduce my portions on vacation...I already know how to do that. I didn't ask her to help with with my cholesterol, I have a doctor for that. She wanted to know why I was taking Omega 3 ...and seemed skeptical of my answer that most people don't get enough, so I figure it would help to take some. I am still so discouraged by this. A few weeks ago I went to the psychologist. There was a questionnaire I had to fill out (essentially about being compliant after surgery). I told him I struggle with exercise now because of my knees...so he suggested yoga. Really? I am obese, with painful knees....if I have a hard time on the treadmill or on the elliptical, why would kneeling on the floor help...? Oh. because you do Yoga. Noted. I tried to create some discourse: The link to obesity and sleep is something I notice...I started to tell him I notice my appetite increases if I haven't slept well because it's like I need to stimulate myself to stay awake. And that turned into getting tested for sleep apnea. I don't have sleep apnea. He mentioned smaller plates to me again (it just seems out of context) So I am feeling like because I am not a total trainwreck, they don't know what to do with me. I totally get that people need more help than 'read a label', but I feel like I have spent a lot of time researching diets, weight loss, obesity etc etc for the better part of 10 or 15 years...and they have not taken the time to find out what I do know. I feel like if I say certain trigger words like 'tired' = Sleep apnea! Wine = Alcoholic! So I don't know what I am supposed to be doing. I feel like I don't know what they want from me. If they want me to lose weight, then I want them to say it. If they want me to stop this or start that, then say it, and have a purpose. I have read all sort of literature about WLS and Set points etc etc and when I go to these appointments I don't want to walk away feeling like they think I am obese because I opted for a banana instead of blueberries (hate them) all these years. I want to get more out of this, but I am also very tempted to just try and tune it out and tell them what they want to hear so I can get the surgery. I am just a number, and I somehow have to fit in their flow chart...not the other way around. Does anyone have any advice? I just feel super discouraged and criticized and not looking forward to another year of appointments every month feeling this way. Thanks for your help!

One word of advice: if they try to pass you off on it, ask for a liver panel (also included in a comprehensive metabolic panel). When I went in and asked them to check my gallbladder, they still weren't convinced, but to appease me they did some blood work and my liver enzymes were out of wack. The doctor asked me if I drank alcohol. He said either I'm an alcoholic or my gallbladder might be acting up. When the ultrasound came back showing problems with my gallbladder, the doctor apologized to me and said he should have listened to me.

The best thing I ever did preop was to give up the addictive substances. I knew I couldn't have them after surgery, and getting past the withdrawal and cravings beforehand made recovery much easier. So, I gave up caffeine, all alcohol, all sugar, all soda, all artificial sweeteners, colors, flavors. I hadn't eaten wheat (gluten) for years, so that was not an issue. By the time surgery came around, I felt clean and detoxed. I did not eat the jello or popsicles in the hospital. I brought my own broth, herbal tea, and protein drink. Turned out they did have some great tasting gluten free broth that was fine.

hahaahahaha! I think her advice is the standard BS claptrap spouted by most RDs whose job it is to toe the party line with old bs information. "Eat within 30-1hour of waking." Add extra meals to your rotation... Remind me again, aren't you doing pretty well maintaining your present weight? Do you ACTIVELY WANT to gain? If so, then yah. The party line advice is the quickest way to accomplish that. LOL. I would just chalk it up to opinions and asshats...we all have 'em. Right? Nod, say yes mam. Then do your own thing. Do YOU think you have an exercise, food, or alcohol issue? **** I "rawlk" or walk 1 hour a day and try for 7days a week. I don't always hit 7 days. I also try to do 20 minutes of core strengthening and balance work 2 x per week. I'm not as focused on getting this done as I am my walking. ***** And lastly, I'm crazy busy right now. And realized I hadn't logged my food since Saturday--until today. I probably won't go back and log in past days cuz no time. But I'm still sitting at 131.6lbs today. (I have been eating mostly the same foods each day so...basically my same top of the week routine. But I'm a logger through and through! Love it. It's mah jam!

Hello to anyone out there who is reading this. it has been 11 years since my gastric bypass and wow! I was reading my past entries things have certainly changed for me. I had the weight problem, lost about 90lbs, became an alcoholic, got divorced, remarried, moved to Houston, then back to Atlanta, became born again, through the peace and grace of Jesus Christ!, traveled monthly to RI to check on my parents, lost my brother and father in 2019, relapsed with alcohol several times, as of today I have been sober for 2 years!~~~~WHEW! So now I am married to Michael White, someone I have loved for over 30 years, I am living sober, grieving the loss of my brother, Chip 01/09/2019 and my Dad, Ray 09/06/2019. As for the weight, I am now 208lbs and not really happy at this weight, but Thank God it's not 275! The most important part of my journey is that I became a Christian, I would have been dead by now if I had not done that. I feel okay today, some days are difficult because I do not drink alcohol anymore, so I have to depend on God through everything...opps gotta run....

I do not and will not buy any foods or snacks that I like. I only have in my house the good foods and if I want to "binge" I can have 3 no sugar added Outshine pop cycles. I know what I like and I know that having it in the house gives is like pouring an alcoholic a drink. You just don't do it. Find an Overeaters Anonymous to help you deal with your food compulsion. You will find others with the same issues you have.

Hey everyone, I went to my PCP on 2/18/19. I weighed 298 lbs at 6 tall. I was huge. Depressed, sleep deprived, eating disordered etc. My Dr. recommended me to the options program at Kaiser. 12 weeks of weekly classes to see if I was ready for the surgery. During those 12 weeks I researched weight loss drugs, and went on Metformin every morning and Bupropion x2 a day. I immediately lost interest in food and over the 12 weeks lost 45 lbs. I'm not diabetic but very hypertensive and sleep apnea severe. They approved me with no out of pocket costs for the surgery tomorrow at 7 am PST. The reason I'm doing the surgery is that I have a 3 year old daughter, and I want to be around for her. I'm late 40's and sick and tired of being sick and tired. My Dr. requires a liquid diet for 2 days before the surgery. I had five fast food dreams last night and dreams about chocolate candy bars and dreams about triscuits and cheese plates, etc. I cant believe I didn't struggle for 12 weeks of losing 45 lbs but 2 days of no solid food and its a huge struggle. Clear liquid protein, broth and lots of caffeine. I got really irritable at dinner time tonight and was frustrated. Even after losing 45 lbs I still ate unhealthy and had trouble controlling my appetite and had serious unhealthy disordered food cravings etc. The frustrating part was after losing 45lbs the teachers in my weight classes and my pcp and my specialists were all like why are you doing this? You are now on the border of obese and look really good. They all tried to talk me out of it! My Bariatric surgeon was very supportive and immediately scheduled my surgery. I'm excited and nervous. The really hard part is that not eating solid food for the last 2 days has been difficult and made me want to regress and go back to junk food! I didnt and I'm ready for the surgery but I hope my taste buds change and I become much healthier and practice mindful present eating habits. I know the Metformin and Bupropion were temporary battles won but not the war - which is why I signed up and I'm ready for surgery. I have my sugar free popsicles, and Premiere protein clear gatorade looking bottles and my vitamins and crystal light sugar free. I'm ready to win the war and this is a battle I knowingly go into with open eyes and a clear heart. I hope the surgery really helps the anger and depression and manipulative hormones that emanate from my stomach when it doesnt get its fast food or junk food fix. I want to enjoy not having an appetite and eating small healthy portions of healthy food. I want to be the 190 lbs guy from my college days. I have broad shoulders and a football players body and played in college but really just get healthy again. Two things I enjoy in moderation is 1 cup of coffee a day and once a month having a drink of alcohol or two socially. I hope I can regain both of those in the year after the surgery. I don't care about the junk food, fast food, and sugary or fried food. I hope I don't ever want those again. (My stomach is talking now) literally 8 hours before the surgery! Mark PS I hope losing weight helps the sleep apnea and lessens it, since the cpap doesnt work very well. I also hope to stop the 4 blood pressure drugs I'm on as well.

Okay so backtracking momentarily on what potentially counts as “cheats” I’ve had a few pre-planned events PO (anniversary, vacation, holiday, wedding, family bday, family lake house weekend, big football games) On almost each of these occasions, I’ve indulged. What (to me anyway) is critically important is that it was PREPLANNED indulging. It wasn’t “accidental” it wasn’t “spur of the moment”. I knew ahead of time I was going to go off plan for a specified period of time and I enjoyed it and then immediately got back on plan because well.... I PLANNED it. To me, that’s the difference between whether we will run the program or the program will run us. As long as I’m going in the direction I need to go, I’m fine with it. This is the rest of my life and it will include feast/fast periods. I’m not ashamed to admit that I LOVE cocktails, beer, and wine and well over 3/4 of my indulgences have been alcohol-related. The last 3 weeks I’ve been completely on-point. I’ve been

I try to stick with decaf tea. Here is the reason. I used to be a huge coffee drinker. When I gave up sugar and caffeine, my energy levels stabilized and evened out unbelievably. No need for the morning wake up cup, no afternoon slump. Just really level throughout the day. It made me see how addictive both substances are, but also how much caffeine really is a drug in a sense. I like feeling energetic WITHOUT needing caffeine. I do have a regular tea in the mornings sometimes, especially the chai flavored ones, but then it is water for the rest of the day and herbal chamomile in the evenings. Every drink of alcohol damages tissue. Period. Once someone is down the road a bit, and the tissues are completely healed, a little wine with a meal once in a while probably won't do anything significant. Regular intake is dangerous, in my opinion, for the damage it can cause, and also the possibility of transfer addiction. Again, I don't want to NEED anything. After having no wine or alcohol for so long, I don't miss it at all. I realize the only reason I liked it was for the sweet aspect, going back to sugar. Alcohol also has a lot of empty calories. I can see no reason to drink again (for me). It has absolutely no nutritional benefit - (at least none that can't be derived from fresh food), and only the possibility of harm. I am trying to make my eating as clean and nutritionally dense as possible. Alcohol doesn't tick the boxes.

What is your experience with caffeine from tea? I am 8 months out and had maybe 2 oz of coffee with some milk for the first time. I was really tired and don’t plan on doing that regularly but I would like to have tea this winter. In your experience was the alcohol causing the ulcers from regular drinking? I would like to have a small glass of wine a few times a year but not tempted to even try it yet.

Well, it gives a different view on things. The author herself had years of therapy that didn't do zilch for her bingeing. She refers a lot to "Rational Recovery", a book that was written for people addicted to alcohol.

I had to do three visits and each one we discussed different things and I weighed in at each. My first visit was discussing goals they required us to meet before being cleared for surgery, like no caffeine, no alcohol, logging food, etc. We checked off which ones I already do and discussed how I would meet the other ones before my last weigh in. The other thing we really discussed was what a typical day of eating for me would be right now and what it'll look like after surgery. Nothing too scary! Have fun with it! Let us know how it goes 😃

Thank you @Bastian and @FluffyChix I haven’t answered I’ve been in a mood. My weight did a bit of a backslide after the colonoscopy and endoscopy. Three days of prep I got in less calories than usual but got my average protein in 52 grams. Colonoscopy day I only managed a packet of BariatricPal cappuccino (80 calories, 15 grams protein) the past two days I had around 60 grams protein. My weight was down the day of the colonoscopy but then backslid. My nutritionist wanted me to try new food I tried smoked salmon last night she said it was ok to try It was soft enough to not have a hard time going down. Tasted fine, I ate extremely slow. But I was nauseous and got a migraine. I admit my mom asked me to go out to dinner with her friends. The day after the tests. I had enough protein that day I had a few small bites of her sweet potato and a drink I sipped very very slowly, nothing with added sugar, some crushed ginger and lime, my first time having any alcohol for a long while, it wasn’t a sweet drink. I don’t usually go out I am terrible in social settings and all the loud voices in a restaurant, so that’s why I got a drink hoping to relax me, to numb the throat pain, even though I felt no effects from it at all. As for the colonoscopy and endoscopy they never give a option of what time it is. They also require I do prep the night before and the morning of or drink it five hours before the procedure. I had no idea that a noon appointment was their last patient. This was the only availability otherwise the wait was a month or two longer. You are right the stoma is the GJ junction, so then GE junction is gastroesophageal junction. How do they tear that during dilation of the stoma? No one talked to me because I wasn’t alert enough. So it was my fault I had an involuntary hiccup? Probably from having to try to do all the prep despite the Dysphasia. And then my follow up isn’t until November 27th! I’m just getting frustrated with doctors, with myself, with just about everything lately. This could just be a normal stall before it starts but I hate the backsliding, for me it triggers a sensation of ptsd and I feel like I can’t keep from going back to being fat even though I try so hard. I also feel like my metabolism is just so slow I’ll never be able to eat normal calories even after surgery that I’ll have to stay below 400 calories and stick to around 50 grams protein. My nutritionist wants me eating more normal foods and I’m afraid it will trigger more gain even if it’s within calories and protein. Never mind the swallowing issues. Not sure when or how to discuss the colonoscopy and endoscopy or if the doctors will even care. And I need to prepare for surgery on the 14th and hope I can keep my weight going down despite that. With my lifelong chronic illness constantly getting worse, and dealing with new unknown neurological problems, I can’t deal with setbacks with other things. Especially my weight. It may seem like a small thing to me it’s a big thing. But I have no control over much of my life it’s one medical thing after another and needs to work around fatigue and post exertional malaise. I don’t want people thinking it’s a pity party. I’ve had my mom accuse me of that. It’s just my reality. I feel rather stupid venting on a public forum on the internet again. I hadn’t done this in a while. I’ve got no one. My moms boyfriend seems to think because I “look good” automatically I should be perfectly fine and have no problems. I try to be a part of my mother and her friends sometimes but it’s not my place here it’s hers and her life. I just feel like the idiot with autism and chronic illness that no one wants to hear exists. So then I don’t get involved. When we moved here I encouraged my mother to take advantage of the opportunity to do so, and to get away from our life in NY so she could have a better life for herself. It was never for me. And the one thing I enjoyed most about being here, going on walks to photograph birds and critters and nature, is getting further away from being possible. I tried to tell my mom these things, she doesn’t want to hear it just says she is worried but she gets to go about her life. Of course she should. I say she is better of without me but she says she needs me. Story of my life. I’m never good enough. Again I rant. I’m Sorry about that.

@Brent701 I don't feel I can maintain this restrictive diet on my own long term that's number 1. Number 2 the RNY BYPASS does a lot more than just restrict the amount of food, it completely rearranges your system and changes your metabolism for the better and I believe I need all those things plus the Malabsorption for my long term success. Number 3 losing weight is not that hard. it's keeping it off and maintaining it for years to come that's where the surgery will increase my chances of long term success. In the past I've had traumatic experiences in life that have sent me completely off track where I would indulge in all things like bad carbs and take away and generally overeating plus I was an alcoholic for many years but gave that up. I still get cravings when I see things on tv like a nice big juicy burger or steak but I have to remind myself why I am doing this... Thanks for your response

watch out with the drinking. Not only can you sabotage your weight loss, transfer addiction is REAL. Alcohol tastes way better to me now that it did before surgery - so I avoid it like the plague. The last thing I need is an alcohol problem...

You probably didn't do a lot of damage to your weight loss, but the reason for no alcohol is to prevent tissue damage to the surgical sites. Alcohol can cause erosions and ulcerations - even years later. I know everyone makes their own decisions, but personally, I think it is best to avoid alcohol forever after WLS. I am a GI nurse and the worst ulcers I have ever seen are in WLS patients who started drinking again. It is pretty horrible. These tissues seem to remain fragile forever, and we need to do all we can to take care of them. I gave up sugar because I don't want dumping. I gave up coffee and alcohol because I don't want ulcers. Gave up soda, as I already had fatty liver disease, and soda contributes to it (diet as well as regular.) Gave up simple carbs because I don't want to be fat! BUT...... got a whole new life that is so precious and worth taking care of.

I was told no alcohol for 6 months. Couldn't even have on on my birthday.

I was a fan of fruity drinks and Long Island Ice Teas. However, as I did keto WOL for so long before surgery, I went to having an occasional diet coke and rum (technically keto friendly), HOWEVER, this was more of a once or twice a month thing before surgery. For me, since I"m only 8 weeks out and I'm in my THIRD stall AND I am a very very very slow loser even sticking to my dr's plan 100%, while I have had brief temptations, I know I'm 1) Not Ready to try this 2) Unsure if I should ever try it 3) Not willing to add something else into the confusing equation of why I am stalled yet again All this being said, I will not lie and say that I feel 100% confident that I will never have another drink. We are going on a Christmas cruise with my 89 year old MIL as she wanted the whole family to be together at Christmas and wanted it to be on a cruise...so we are all going. I have wondered about the possibility of having a drink at this time.. Unfortunately I will be only 5 months out at this time. I wish it was more like 1 year. I'm also unsure if I want to try my 1st drink, if I even do, on a ship with my whole family around...have no idea if it goes awry, how fast I could get to a place of privacy....you know? I have wondered what in the heck I would 'mix' any alcohol with and my eldest pointed out that my Premier Clear Protein Tropical Punch drinks would probably work...I was like "yeah, thanks for pointing that out...and now it is in my head". Only thing I know for sure is that for today, I choose not to drink alcohol.

All of us here are food addicts to some degree or another, or else we wouldn't be here at all. My question to you: Are you willing to take the scary steps to give up your addiction? You WILL lose weight with surgery - no question, and you will be given a grace period of 6-18 months in which to learn new behaviors and new ways to cope with stress and emotions. Are you willing to learn new skills? If so, you will be successful. The other warning for all of us is the issue of transfer addictions. We MUST learn new coping mechanisms or else risk other addictive behaviors like alcohol, drugs, gambling, shopping, etc. There is simply no easy way to overcome obesity and all the related issues without commitment and a willing heart. Counselling is very important for many, as this is uncharted territory for all of us. I can assure you that there are plenty of tools and resources available. The bottom line is whether or not you are willing to make the lifestyle and dietary changes. You cannot possibly figure out all the answers at this point - it is a journey of discovery. But if you are willing, the help is there are you will be successful.

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?