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Thanks for your input B-52. You sound like you are truly listening to what your body and band want and disciplined enough to follow through with that. I think the majority of people who diet and lose and gain is because there is lack of discipline..desire is there, but our bodies tell us to eat when we KNOW we should restrict our diets. This is why diets fail and why we all got banded..but the same patterns of behavior are there that got us and kept us fat!! There are folks who successfully could lose weight on WW, Jenny, diet book of the day, etc etc and keep it off because they had that discipline. I like the idea of giving the pouch and esophagus a rest. I will incorporate that. DEFINITELY will be more mindful of what I eat and how much. My motivation to stay at my weight was all about leather! A one piece very unforgiving of even a few lbs weight gain motorcycle track suit. I love to do track days and it has been depressing to have had to miss out because this extra weight prevented me from fitting in that suit. I was gifted a suit form track friends in a larger size and had it altered a bit, but I told the leather guy that by the time next track season starts, I am hoping I fit back into my old one OR he has to alter the larger one down. I stare at my closet full of clothes that no longer fit, but also look at pics of me and want THAT person back again..the one that felt better in her body, achy joints back, not feeling like a lead balloon hauling around an extra 40+lbs. I think I will keep these size 14 work pants out when I get back into my usual 8's as a reminder to never go through this again! Tomorrow is the day for the journey to refills.. keep you all posted on how it goes! Green Zone here I come!

Hiatal hernias are common in obese people and common in people with reflux, whether or not they're obese. The band can resolve reflux by acting as a barrier between the stomach and the esophagus, but a band that's too tight can also cause reflux. You need to ask your surgeon about why. Also, it's not uncommon for hiatal hernias to develop after massive weight loss. Again, ask your surgeon why. I know several bandsters that's happened to. The gastro doc who diagnosed my hiatal hernia 20+ years ago told me that hernias usually develop in people who were born with the potential - they have a weakness in the diaphgram, and weight gain can aggravate it enough to encourage a hernia to develop. Finally, large hiatal hernias are considered a contraindication for band surgery, but most surgeons repair the hernia during band placement.

This is a thread that should be read by band doctors (if there any out there that are still putting in bands!). Like the OP, I'm convinced that once an unfill is performed, it is unlikely that a refill back to the same level of original fill will provide the bandster with the same, good level of restriction and feeling of satiety. My sense is that you have to go up and over the original fill level to find, if it is even possible, the green zone again. So many on this board never find a sustainable green zone again after an unfill. What all pre ops should know, and what all banding surgeons should tell them, is to take the utmost care of their bands, working them to the max in the first year of banding. That's where we all see the most weight loss...motivation is at its highest, and the band and the banded area is pristine. Barring a surgery screw-up or medical issue, no unfills should have to happen in the first year if the patient is compliant with the post op way of eating. There are a couple of well-known bandster bloggers who just had unfills followed by refills and are now struggling with weight gain (small, but gains nonetheless). Anyone read Chronicles from Bandland or Lapband Gal? Both are star bloggers, longtime bandsters with perfect track records for compliance. Both lost massive amounts of weight and got to goal in their first year. Now, five years out (more or less) both have had issues and have had to get slight unfills. LBG got refilled but her weight is up a bit, and CfB has gained a bit and can't get it off, even with restricted calories and lots of sport. The minute the band gets tinkered with, weight will seek to return...even if we are eating the same amount of calories as before. It's an area that really should be studied but of course won't be because you can't control the study unless you lock up the patients and control their caloric intake. But damn I wish a medical team would look at this and figure out why it happens! And then find a way to stop it from happening!

Just made it to ONE-derland! (Does anyone remember that song, Boogie Wonderland by Earth, Wind, & Fire??) Well, I been singing it all day. Yesterday, I weighed in at 200.0 pounds, but this morning I weighed in at 199.6. To celebrate, I bought myself a cute blouse in a medium (and I must say I look super cute in it); it's off the shoulders with a mixture of blue colors and I'm gonna wear it with my skinny jeans when I cook this Wednesday for my family. I must add, I didn't get here easily. It's been the gym 5 days a week (sometimes there at 4:00am), watching and logging what I eat, along with a mixture of stalls and even a few weight gain weeks, and of course I work full-time and I am pursuing a master's degree. When I don't hit the gym, the scale does NOT move (even with the sleeve). So I'm gonna celebrate my new super cuteness then hit the gym again to get the next 64.6 pounds off! ...dancing in boogie ONE-derland...

Hi! So I received the RNY gastric bypass on September 23, and just got home out the the hospital yesterday. 11 days in the hospital. I'm in a crazy amount of pain and it's really hard to do simple things like getting out of bed and going to the bathroom. My surgery journey isn't at all what I had planned. What happened was after the first surgery, on the 23, I was throwing up, weak, and other gross things. The doctors checked on me every few minutes because they were worried they were going to lose me. So they rushed me to a different hospital for surgery number 2 to fix the problem found in the c t scan. They said I was born with an abnormally shapened stomach and it has always been larger, and that the weight gain my entire life hasn't been my fault and it was a medical issue! If I hadn't of gotten the surgery they said my stomach would have crushed my spleen. So the second surgery gave me a Omega Loop to help alter routing of my insides. So many things are horrible and went wrong, and I'm really starting to think this was the wrong thing for me. I'm eighteen, and this has been an abnormally amount of anxiety in my life. I have to drop out of classes this semester and quit my job to focus complete on healing. I just needed to share my story so far and look for some encouragement. Also, I'm hungry, is that normal? I'm worried that this didn't work. I eat my puréed food plan me always feel hunger after and like I can eat more. Advice?

Hello All, after being away for quite some time I am BACK to inspire, motivate, encourage and to be encouraged. I had my gastric bypass in Sept of 2015 and today I weighed myself and the SHOCK of seeing the scale read 201after 5 years was a SLAP in the face. Now today I need to lose 35 pounds. I need all of your help and encouragement. How do you lose weigh post gastric bypass? Can my stomach shrink? Has anyone else had this experience? Help need to reach my goal weight again. Please see recent photo below.

Frustrated by a weight loss plateau? You need a combination of patience and a plan to push through it. It happens to everyone sooner or later. Your bandwagon stalls. You’ve been going great guns, fired up with enthusiasm, working that tool, doing all the right things, and losing weight. Then one day the weight loss stops. One day, two days, twenty days go by…you’re still stuck, and you’re wondering what happened. And because you’ve spent so many years failing at dieting, and being told that obesity is always the fault of the patient, you start to wonder what you are doing wrong. You even think, “Is my band broken?” Chances are, you’re not doing anything wrong, and neither is your band. What’s happening is that your body is adjusting itself to the many changes that have happened during your weight loss. The human body doesn’t know what you’re going to do next, be it climb a mountain or relax on the couch, so it has to continually adjust and readjust your metabolism to make the best use of the calories you take in. It looks at the history of what you’ve been eating and how much you’ve been burning off through physical activity and comes up with a forecast of what you’ll need to stay alive for the next week or so. THIS MONTH’S WEIGHT LOSS FORECAST IS… At work I’ve had to prepare sales forecasts for various jobs through the years. How many widgets will we sell in the month of April? How many defective widgets will be returned by unhappy customers who want a refund? Will all this income and outgo generate enough cash (in our case, energy) to cover the payroll and the equipment maintenance and the CEO’s country club membership? I once had a boss who joked that we might as well toss a deck of cards down a flight of stairs to come up with a prediction of which new product (represented, say, by the joker card) was going to be the best-seller. That suggestion didn’t go over big with the finance guys. Like us, they were trying to follow the rules, keep everything identified, counted and categorized. And like the bean-counters, we count our calories, carbs, fats, proteins, liquids, solids, income, outgo, with faith that this accounting system will help us win the weight game. Meanwhile, our bodies have a different agenda: survival. When we decrease our food intake and increase our physical activity, the body watches to see what will happen next. As our purposeful “starvation” continues, the body struggles to accommodate the changes we’re making. It makes some withdrawals of funds from our fat cells and fiddles with our metabolism to prevent an energy (calorie) shortage. Gradually it becomes acclimated to the new routine so that it’s making the best possible use of the few calories we’re consuming. It’s keeping us alive, but it’s also putting the brakes on weight loss. Eventually we find ourselves stalled on what seems like an endless weight loss plateau. And unless we change our routine and keep our bodies working hard to burn up the excess fat, we’re going to grow to hate the scenery on that plateau. AND ON THE FLIP SIDE I’ve suffered through countless weight loss plateaus but by varying my exercise, my total caloric intake, my liquid intake, my sleep, and so on, did manage to finally arrive at my goal weight. For the past few years, I’ve felt mighty smug that I finally got promoted to the Senior VP of Weight Management here at Chez Jean. Maintaining my goal weight +/- 5 pounds seemed effortless. But it didn’t last. Turns out it was time for me to learn another lesson about my body’s fuel economy. When I had all the fill removed from my band to deal with some bad reflux, my eating didn’t go berserk. I didn’t pig out at Burger King, didn’t drown my sorrows in a nightly gallon of ice cream. I was definitely eating more because I was so much hungrier than before – perhaps 500 extra calories a day, which would amount to a weight gain of one pound a week. Imagine my dismay when I gained seven pounds in 2 weeks – the equivalent of an extra 1750 calories a day! There was a time when I could have overeaten that much without any effort at all, but as a WLS post-op, I’d have to work hard at eating that much extra food. I was flabbergasted. And frightened. Obesity was a mountain on my horizon again – far in the distance across my weight maintenance plateau - when I thought I’d left it far behind. So at the end of a visit with my gastro-enterologist during that scary time, I asked him if my sudden and substantial weight gain was the equivalent of my body shouting, “Yahoo! We’re not starving anymore! Let’s get ready for the next starvation period by hanging on to every single calorie she takes in! Let’s store those calories in those fat cells that have been hanging around here with nothing to do! C’mon, troops, get to work!” I’m pretty sure that’s not the way Dr. Nuako would have explained it, but he smiled, nodded, and said, “Oh, yes.” I felt like I was facing the flip side of a weight loss plateau: I might be in a weight gain plateau. All I could do is keep on keeping on with exercise and healthy eating, enjoying some of the foods, like raw fruits and veggies, that had been harder for me to eat with a well-adjusted band. PUZZLING OUT THE WEIGHT LOSS PLATEAU So the good news was that my wonky metabolism following that complete unfill wasn’t my fault, but the bad news was that my metabolism wasn’t in a cooperative mood. I was going to have to start playing much closer attention to the details of weight loss and maintenance again. What a pain! But hey! I’d already had a lot of practice at that. I had the tools – a little rusty maybe, but still in usable condition. I ended up regaining 30 pounds between that unfill and my revision to VSG, but I have a suspicion that without those weight tools, it could have been 60 pounds. And that’s one of the reasons that even today, bandless for 14 months now, I don’t regret my band surgery. The band helped me lose 90 pounds and learn a host of useful (if uncomfortable) things about myself, my behavior, my body, my lifestyle. What about you? How can you get your weight loss going again and avoid regain? So many factors can affect your weight that sorting out the reason(s) for your weight loss plateau can make you dizzy even if you’re not a natural blonde like me. To help you assess what’s going on and what might need to be changed, I created a Weight Loss Plateau Checklist. To access the checklist in Google Docs, click here: https://docs.google....emtSYjJLRnVGTFE The checklist includes a long list of questions about you and your behavior, with answers and suggestions for each question. I can’t claim that it will give you the key to escaping that plateau, but it should give you some food for thought and perhaps some ideas to try. Use that to come up with a plan to deal with the plateau, and work that plan for at least a month to give your body a chance to get with the new program.

I am considering having a revision now due to weight gain during pregnancy. I didn’t gain back all my weight. 50 lbs out of the 117 I lost but I have been dieting for months and it’s just not coming off.

I do get disappointed at times. I lost most of my weight directly after surgery and now am averaging 1-2 pounds per week. I am eating on average 1100-1200 cals/day and am rather sedentary. I'll remind myself that I'm losing consistently, mostly do not feel the insanity with food--the BEST GIFT I could've been given, and am making permanent changes in the way I eat. I know I'll not only reach my goal in time but more importantly will be able to manage my weight long-term. In my experience, reaching goal quickly lends to more grandiosity which leads to rebound weight gain.

1. This procedure is relatively new so long-term data is hard to find, but check out the pinned topic "Weight Gained Since Being Sleeved." A lot of long-termers talk about their success on that thread. 2. I'm not super awesome about taking my Vitamins. I take them a couple times a week, when I remember. I spent a lot of money at first trying to find vitamins I liked. I bought a few different B Complex ones until I found ones that didn't smell horrible, and I had to buy different Calcium chews because I bought the wrong kind. I don't even notice it in my budget anymore. 3. I'm 10 months out. No psychological issues so far. Nothing but joy, really. I check myself out in the mirror, a lot. 4. I think I got lucky here too. I love shopping now, but my budget helps keep that in check. I enjoy cooking a lot more now, and making "normal" (protein-rich) recipes instead of the low-cal/low-fat/low-flavor crap I was cooking while dieting. I do drink, but no more often than before, and less volume because I get tipsy faster. Hope this helps.

Yes, my preop surgeons visit, I asked that question of weight gain w the sleeve bc I'd seen a lady who had gbs n gained it all bck n then some...he said yes, w any1 of the surgeries mentioned, u can gain it all nd more bck IF U CHOOSE to make the SAME BAD CHOICES AS PREOP, the surgeries are all tools, aides, to help us succeed, NOT MAKE US SUCCEED, it is still going to b up to the patient to make the tool work w u, not for you:) hope that helps nd makes sense to u. If u think its going to stop you from making bad choices, u shud rethink ur decision, the only thing that can do that is wiring ur mouth shut, then ud prolly die:/ start learning all u need to know about how to use the new tool, sleeve, prior to getting it. I mean, u can't know how to build a house just bc som1 handed u a hammer, it won't build itself, right? And u can't build a better more healthier you wo knowing how to work w ur sleeve. So gl to us all:))

I am having heavy bleeding during my menstrual cycle. My Obgyn said its because of the weight gain, after I lose the weight it will go back to normal. I'm looking forward to it going back to normal.

That's great you are finally going to a psychiatrist. The know much more about issues like bipolar than your family doc. I take 2 meds for bipolar. One possibly causes weight gain but it didn't for me. I lost steadily on it. I would take the meds prescribed for a couple weeks and see how it goes. If you are doing all the right things and still don't loose than you can decide what to do. For me, I'd rather stall in weight loss for a bit than suffer with deppression/anxiety. Good luck!

In the last several years, I have shrunk from 5'10" to 5'8.5" (it won't let you put half inches on here, so I am listed as 5'8")... I am wondering if, when I lose the weight, I will gain that 1.5" back? Has anyone experienced this?

I think weight gain because of medication is something different than "the usual" regain so even if there were more veterans talking about this issue it might very well be that it's not helping you. However, maybe there are some veterans on this board who need to take similar meds and still maintain? Is there a chance that your meds can be reduced again in the future? There seem to be different strategies. I notice that several veterans talk about how they maintain their weight. It can usually be found in the threads about regain.

It makes things easier when you lose weight prior to getting sleeved. Firstly, your liver is less congested when you lose weight, so it is more apt to be out of the way and less likely to be inadvertently nicked or scraped by the surgeon during the procedure. Finally, losing weight before surgery gets you that much closer to your goal weight. Do not be like me: I actually gained 25 pounds while waiting to be sleeved due to maladaptive food funerals (a.k.a. overeating all my favorite foods one last time before saying "goodbye"). My initial consultation weight was 200 pounds and I was up to 225 pounds one week before the surgery. Thank goodness my surgeon and insurance company had no issues with my substantial weight gain. I did reach my goal weight, but the weight gain prior to the sleeve was a setback. If I could do it all over again, I would have ensured my head was into the right mindset earlier in the process. Good luck to you.

Here is an academic overview of the various bariatric procedures with a bit of excess 'science stuff' thrown in. No opinion. No bias. Published 2012 by the UK Royal College of Physicians. If anyone requires further clarification to the sources contained (hopefully its been copied successfully), please see the reference list at the end. This will provide you (licensing permitting) with a link to those original source documents so you can do your own further research/analysis. Any questions or queries, please do not hesitate to ask. Revs x Overview of bariatric surgery for the physician Keng Ngee Hng, Specialty registrar in gastroenterology1⇓ and Yeng S Ang, Consultant gastroenterologist and honorary lecturer2 + Author Affiliations 1Salford Royal NHS Foundation Trust 2Faculty of Medicine, University of Manchester, Oxford Road, Manchester Address for correspondence: Dr KN Hng, 4 Fern Close, Shevington, Wigan WN6 8BL. Email:keng_ngee@hotmail.com Abstract The worldwide pandemic of obesity carries alarming health and socioeconomic implications. Bariatric surgery is currently the only effective treatment for severe obesity. It is safe, with mortality comparable to that of cholecystectomy, and effective in producing substantial and sustainable weight loss, along with high rates of resolution of associated comorbidities, including type 2 diabetes. For this reason, indications for bariatric surgery are being widened. In addition to volume restriction and malabsorption, bariatric surgery brings about neurohormonal changes that affect satiety and glucose homeostasis. Increased understanding of these mechanisms will help realise therapeutic benefits by pharmacological means. Bariatric surgery improves long-term mortality but can cause long-term nutritional deficiencies. The safety of pregnancy after bariatric surgery is still being elucidated. Introduction Obesity is a worldwide pandemic,1–4 with the number of obese children and adolescents increasing alarmingly.5 This has serious health and socioeconomic implications due to the attendant increase in related comorbidities.1,2,4,6 Obesity causes type 2 diabetes, hypertension, dyslipidaemia, cardiovascular disease, obstructive sleep apnoea, obesity hypoventilation syndrome, cancer, steatohepatitis, gastro-oesophageal reflux, gallstones, pseudotumour cerebri, osteoarthritis, infertility and urinary incontinence.1–6 Severe obesity reduces life expectancy by 5–20 years.1 Diet, exercise and drug treatments for severe obesity have been disappointing.1–3,5–12 At the present time, bariatric surgery is the only treatment that reliably produces substantial and sustainable weight loss.1–7,9,13 It is indicated in people with BMI >40 kg/m2 or with BMI >35 kg/m2 in the presence of significant comorbidity.3,5,7,14 Bariatric surgery is cost effective,3,6,15 achieving weight loss, as well as improvement or resolution of associated comorbidities.1,2,5,6,9,15,16 In the past decade, the development of centres of excellence,5,6laparoscopic techniques,2,5,6 improved safety profiles2,6,9 and better documentation of clinical effectiveness2,6,15 have fuelled an increase in the number of procedures performed. Types of surgery Bariatric surgical procedures are traditionally classified as restrictive, malabsorptive or combined according to their mechanism of action. The procedures most commonly performed are laparoscopic adjustable gastric banding and roux-en-y gastric bypass.3,13 Sleeve gastrectomy is increasingly performed.2,6,7 Biliopancreatic diversion and biliopancreatic diversion with duodenal switch are much more complex and performed infrequently.2,5,17,22 Other historical procedures are no longer in common use. In addition to restriction and malabsorption, recent evidence suggests that neurohormonal changes are an important effect of bariatric surgery.2,6,7,17,18 Bariatric surgery is only part of the management of severe obesity. Careful patient selection and preparation are extremely important, as are long-term compliance with diet, nutritional supplementation and follow up.2,5,6,19 Laparoscopic adjustable gastric banding2 A purely restrictive procedure, laparoscopic adjustable gastric banding (LABG) is the least invasive procedure, is completely reversible and has the lowest mortality.19 A silicone inflatable band is placed around the stomach cardia immediately below the gastrooesophageal junction (Fig 1). This is connected to a subcutaneous port that is used for band adjustment.5,6 The band compresses the cardia to generate a sense of satiety and reduced appetite, which is thought to be mediated via vagal afferents.2 Roux-en-Y gastric bypass (RYGB) is a combined procedure that is also performed laparoscopically. A 20–30-ml gastric pouch connected to the jejunum forms the Roux limb (Fig 2). The disconnected duodenal limb is anastomosed 75–150 cm along the Roux limb, forming a Y configuration. The distal stomach, duodenum and part of the proximal jejunum are thus bypassed.5–7,20 Despite the traditional classification of the this procedure, malabsorption is not significant with the standard RYGB surgery.7 In an extended gastric bypass, the Roux limb is lengthened to increase the malabsorptive component.6,20 In sleeve gastrectomy, 60–80% of the stomach is removed along the greater curvature to leave a restricting ‘sleeve’ of stomach along the lesser curve (Fig 3).5,20,21 Originally the first step of the biliopancreatic diversion with duodenal switch (see below), sleeve gastrectomy has evolved into a staging procedure for super obese or high-risk patients.2,5–7,20 It is also increasingly used as a standalone procedure.2,6,7 Biliopancreatic diversion (BPD) and biliopancreatic diversion with duodenal switch (BPD/DS) are malabsorptive operations that result in bypass of most of the small intestine. With BPD/DS, a sleeve gastrectomy is performed, leaving the pylorus intact. The duodenum is then disconnected and the stomach anastomosed to the distal small bowel (the ‘duodenal switch’), creating a short alimentary limb. The long biliopancreatic limb is then anastomosed to the ileum 75–100 cm proximal to the ileocaecal valve, so digestion and absorption occurs only in the short common channel.5,6,20 With BPD, a partial gastrectomy leaves a 400 ml gastric pouch and the common channel is shortened to just 50 cm.5 Safety profile and complications Bariatric surgery is safe.2,5,6,9,22–24 High-volume centres of excellence deliver bariatric surgery with inhospital mortality of 0.14% and 90-day mortality of 0.35%, which is comparable to that for cholecystectomy.6 Acute complications, including haemorrhage, obstruction, anastomotic leak, wound infection, cardiac arrhythmias, pulmonary emboli, respiratory failure and rhabdomyolysis, occur in 5–10% of patients.5,6,9,10,25 Long-term complications include internal hernias, anastomotic stenoses, marginal ulceration, fistulae, diarrhoea, dumping syndrome, gallstones, emotional disorders and nutritional deficiencies.5,6,13,15,20,25–27 Patients with LAGB can experience port problems, stomal obstruction, band slippage/erosion, pouch dilation, gastro-oesophageal reflux and oesophageal dilation.5,13,19,25 Malnutrition is a concern with BPD with or without DS.1,17 Long-term risks for sleeve gastrectomy are unknown.5 The Longitudinal Assessment of Bariatric Surgery22 reported overall 30-day mortality of 0.3% for 4,610 patients having LAGB or RYGB for the first time, with 4.3% of patients having a major adverse outcome within 30 days. This was most frequent among patients having open RYGB (7.8%). A meta-analysis involving 85,048 patients reported a total 30-day mortality of 0.28% and a two-year mortality of a further 0.35%.24 The most complex malabsorptive procedures had the highest perioperative mortality at 1.11%. Mortality for gastric banding is between one in 2,000 and one in 5,700.2 Effects on weight, comorbidities and long-term mortality After RYGB, patients lose 60–70% of their excess weight over two years, and this is largely durable.1,2,6,9,15,16,28 Weight loss is dependent on long-term compliance with dietary recommendations.2,5,6 Sugary, energy-dense foods and drinks can ‘bypass the bypass’. After gastric banding, patients lose about 50% (range 39%–59%) of their excess weight at a slower rate, often continuing into the fifth year.1,2,5,6,9,19 Regular band adjustment is necessary.16 The Swedish Obese Subjects (SOS) study reported a reoperation or conversion rate of 31% for gastric banding and 17% for gastric bypass among patients followed for ≥10 years, excluding operations for postoperative complications.16 However, at the centre in Melbourne, only about 10% of patients after LAGB need some revisional procedure, including band replacement, in the following 10 years.2 Biliopancreatic diversion with or without DS produces excess weight loss of 70.1%9sleeve gastrectomy produces initial excess weight loss of 55%, but this may not be durable.2 Bariatric surgery also produces significant improvement in obesity-related comorbidities, with the most remarkable effect being resolution of type 2 diabetes (T2DM). A meta-analysis encompassing 22,094 patients reported complete remission of T2DM in 76.8% of patients,9 and a registry from the UK with data on 8,710 patients reported resolution of T2DM in 85.5% of patients.29 Major improvement often occurs within days after RYGB, before significant weight loss is achieved.5–7,17,18 After LAGB, improvement in T2DM occurs more slowly as a result of weight loss.2,7,19 Combined or malabsorptive procedures produce greater improvement than purely restrictive procedures.1,2,5,9,18 Diabetes less than three years in duration, no insulin requirement, milder obesity with BMI <40 kg/m2 and weight loss ≥10% predict complete resolution of T2DM.18,19 Bariatric surgery is now advocated by some for the treatment of T2DM in patients with BMI <35 kg/m2.4,7,30,31 Bariatic surgery effectively treats all other associated comorbidities: from steatohepatitis and pseudotumour cerebri to urinary incontinence.1–3,5,6,15 Meta-analysis showed that hyperlipidaemia improved in ≥70% of patients, hypertension resolved in 61.7% (and resolved or improved in 78.5%) and obstructive sleep apnoea resolved in 83.6%.9 At five years, the risk of cardiovascular disease had decreased by 72%.3 The incidence of cancer also reduced markedly,6,15,16 as did the risk of developing new comorbid conditions.15 Long-term efficacy is well documented.5,6,28 At follow up after 10 years, the Swedish Obese Subjects (SOS) study showed a 29% reduction in adjusted all-cause mortality, primarily because of decreases in cancer and myocardial infarction.16A retrospective cohort study of 7,925 patients after RYGB reported a 40% reduction in all-cause mortality during mean follow up of 7.1 years.23 Specific mortality decreased by 56% for coronary artery disease, by 92% for diabetes and by 60% for cancer. A large observational study, in which the vast majority of patients had undergone RYGB, reported an 89% risk reduction in five-year mortality.15 Energy homeostasis and hormonal changes Weight loss after bariatric surgery is not explained by volume restriction and malabsorption alone.17 Indeed malabsorption is estimated to account for only 5% of the weight loss following standard RYGB.17 Bariatric surgery causes significant changes in the neurohormonal profile, which contributes to sustained weight loss through changes in appetite, satiety, food preferences and eating patterns and explains the remarkable effect on T2DM.2,5–7,17,18 The hypothalamus32 Hormonal signals provide information about energy status to the hypothalamus. Adipokines are secreted by adipose tissue and enterokines by the gut. Incretins are enterokines that stimulate release of insulin after food intake.18 Two hypothalamic circuits influence food intake, and both contribute to acquisition and storage of nutrient energy. The homeostatic circuit increases appetite and locomotion in response to energy shortage. The hedonic circuit is engaged at stable weight plateaus in association with increases in body fat. It heightens finickiness to taste of food. Obese animals overeat palatable food but undereat bland foods and lose weight. In our current obesogenic environment, the hedonic circuit facilitates the seeking of energy-dense foods uncoupled from energy status. Enterokines Ghrelin,33 which is mostly synthesised in the stomach, is a potent appetite stimulator involved in hunger and meal initiation. Circulating levels are inversely proportional to BMI and respond to changes in body weight. Ghrelin enhances gut motility and speeds gastric emptying.17 It promotes lipid accumulation and weight gain, favouring glucose utilisation. It also inhibits insulin secretion and impairs glucose tolerance.18 Levels of ghrelin reported after bariatric surgery have been variable, which may be due to differences in surgical techniques and research methods.7,18Overall, the trend is for a decrease in ghrelin levels after RYGB and an increase after gastric banding.7,17 Sleeve gastrectomy, which removes most of the ghrelin-producing stomach, reduces levels of ghrelin. Peptide YY (PYY)34 is secreted postprandially by L cells in the pancreas, small intestine and colon. It suppresses appetite and promotes satiety via signalling actions in the brain. It also delays gastric emptying (the ileal brake) and enhances insulin sensitivity.7 Secretion of PYY generally corresponds to the energy ingested, although it may vary depending on the macronutrient content.17Interestingly, levels also correlate positively with exercise intensity, with resulting decreases in food intake. Glucagon-like peptide 1 (GLP-1) is co-secreted postprandially with PYY in the distal intestine.17 A powerful incretin, GLP-1 potentiates glucose-stimulated insulin secretion, enhances β-cell growth and survival, inhibits glucagon release and enhances all steps of insulin biosynthesis.7,17 It also slows gastric emptying to produce greater gastric distension and helps regulate appetite and body weight.7,17 Obese individuals have lower levels of PYY and GLP-1, and levels are decreased further in patients with diabetes.5,17,18 Two hypotheses exist to explain the hormonal and metabolic effects of the RYGB: the hindgut hypothesis the foregut exclusion theory. The hindgut hypothesis postulates that after RYGB and malabsorptive procedures, rapid nutrient delivery to the distal gut L cells and their increased exposure to incompletely digested nutrients lead to an early and exaggerated PYY and GLP-1 response, contributing to early satiety, reduced meal size and early resolution of T2DM.7,17,18 Ileal transposition studies provide strong evidence for this. Interposition of an ileal segment into the proximal gut in rodents produced exaggerated PYY, GLP-1 and enteroglucagon responses, reduced food intake, weight loss, improved insulin sensitivity and overall improved glucose homeostasis.7 The foregut exclusion theory proposes that exclusion of the duodenum and proximal jejunum after RYGB is the mechanism that mediates the effects of bariatric surgery.7,18 However, duodenal–jejunal bypass experiments in rats supporting this theory are compounded by the accompanying pyloric disruption that results in accelerated gastric emptying and rapid nutrient delivery to the hindgut.7 The endoluminal duodenal–jejunal sleeve also accelerates gastric emptying by abolishing duodenal osmoreceptor control of pyloric contraction.7 This 60 cm-long sleeve prevents nutrient contact with the duodenum and proximal jejunum, while biliary and pancreatic secretions flow outside the sleeve, delaying digestion.35 A possible mediator of the foregut exclusion theory is the gastric inhibitory polypeptide or glucose-dependent insulinotropic polypeptide (GIP), which is secreted by K cells in the duodenum in response to nutrient absorption.18,39,40 In addition to its incretin action, GIP promotes lipogenesis,41 with GIP receptor knockout mice protected against diet-induced obesity and insulin resistance,39 while antagonism of the GIP receptor improves glucose tolerance and insulin sensitivity and partially corrects pancreatic islet hypertrophy and β-cell hyperplasia.40 Levels of GIP are suppressed after malabsorptive procedures.18,41 Adipokines Adiponectin17,36,37 is synthesised primarily in adipose tissue, with levels inversely correlated with BMI. It is an important insulin sensitiser, and hypoadiponectinaemia causes insulin resistance and T2DM. Adiponectin also possesses antiatherogenic, anti-inflammatory and cardioprotective properties and may act centrally to modulate food intake and energy expenditure. Weight loss following bariatic surgery increases levels of adiponectin. Leptin38,32 is secreted by adipose tissue and regulates body weight via its action on the hypothalamus. It increases nocturnally to stimulate lipolysis but also increases postprandially to induce anorexia. In addition, leptin plays an important role in glucose homeostasis. Levels of leptin are proportional to body fat, with starvation or energy shortage activating the homeostatic mechanism in the hypothalamus to restore energy balance. However, leptin resistance develops in obesity. Weight loss from bariatic surgery reduces leptin levels.17 Many other enterokines and adipokines exist, some of which may also play a part in producing and sustaining weight loss or diabetes remission after bariatric surgery.17,18 Understanding the mechanisms of action of bariatric surgery will help realise therapeutic benefits by pharmacological means.6,7,19 Nutritional deficiencies Nutritional deficiency is common after bariatric surgery and the risk increases from LAGB through SG and RYGB to BPD with or without DS.20,26,31 The problem is heightened by the fact that micronutrient deficiencies are already highly prevalent in obese patients before surgery.21 After surgery, patients are at particular risk of deficiencies in Vitamins B1, B12, C, A and D and folic acid, as well as Iron, Calcium and Protein.20,26 Lifelong prophylactic supplementation is often necessary, and regular monitoring is essential.26 Investigation of clinical syndromes resulting from malnutrition can be challenging. Anaemia20,27 After bariatric surgery, patients are prone to iron deficiency because of intestinal bypass, pouch hypoacidity and intolerance of red meat. Obesity creates a state of chronic inflammation that can contribute to anaemia. Anaemia can also be caused by deficiencies in folate, Vitamin B12, vitamin E (haemolytic anaemia), copper (anaemia and neutropenia), Vitamin A and zinc. In refractory anaemia, gastrointestinal blood loss must be considered. Bleeding in the excluded stomach, duodenum or biliopancreatic limb is problematic as the usual endoscopic access route is no longer available. Neurological problems6,20 Neurological symptoms can result from deficiencies in thiamine, vitamin B12, niacin, vitamin E and copper or from hypocalcaemia secondary to Vitamin D deficiency. Clinical syndromes includes Wernicke's encephalopathy, peripheral neuropathy, dry beriberi, neuropsychiatric beriberi, pellagra, ataxia, spasticity, myelopathy, muscle weakness, posterior column signs and ptosis. Oedema6,20 Patients with oedema may have underlying heart failure, which can also be due to wet beriberi (thiamine deficiency) or selenium deficiency. Hypoalbuminaemia may be caused by liver cirrhosis secondary to steatohepatitis; severe protein/calorie malnutrition; kwashiorkor; and diarrhoea secondary to bacterial overgrowth, malabsorption of bile salts and niacin deficiency. Eye, skin and hair problems20 Vitamin A deficiency causes difficulties with nocturnal vision and reduced visual acuity. Vitamin E deficiency can cause retinopathy. Thiamine deficiency can present with blurred or double vision. Dry skin, pruritus and rash can be caused by deficiencies in vitamin A, niacin, riboflavin, zinc and essential fatty acids. Hair changes can be due to zinc deficiency or protein malnutrition. Pregnancy after bariatric surgery About half of patients undergoing bariatric surgery are women of childbearing age,8 which introduces specific concerns. Obesity is strongly associated with infertility8 and increases the risk of obstetric complications.8 Yet the effects of rapid weight loss and potential malnutrition in pregnant patients are of concern. Bariatric surgery improves fertility42,43 and reduces the incidence of obesity-related complications such as gestational hypertension, gestational diabetes, pre-eclampsia and foetal macrosomia when compared with obese controls. The effect on premature delivery, miscarriage, intrauterine growth retardation, low birth weight and neural tube defects and the need for caesarean section are unclear.8,43 Maternal surgical weight loss reduces the prevalence of obesity and cardiometabolic risk factors in offspring until the adolescent years.42 Pregnancy seems to have little effect on the surgically induced weight loss.8 Patients are generally advised to delay pregnancy until after the period of maximal weight loss (12–18 months).8 Extra vigilance in preconception, antenatal and obstetric care is required. Conclusion In summary, bariatric surgery is a safe and effective treatment for severe obesity and its associated comorbidities. It is particularly effective in the treatment of T2DM. Neurohormonal changes that affect appetite, satiety, glucose homeostasis and long-term energy balance contribute to its long-term efficacy. Two hypotheses exist to explain how hormonal changes produce these effects, and both may contribute. Patient adherence to postsurgical aspects of management is very important. Pregnancy after bariatric surgery brings additional considerations. Finally, the indications for bariatric surgery are being widened. Acknowledgements Dr Keng Ngee Hng is a specialty registrar in gastroenterology and has previously submitted part of this work for her Master of Science in gastroenterology (Salford University). Dr Yeng S Ang is the educational supervisor for Dr Hng and has refined the ideas, concepts and layout of the previous work. Recent updates are also included within this paper. © 2012 Royal College of Physicians

In my support group- one of our mantras is trust the process. I’ve never been fast loser. But I’m steadily losing. Then of course having to take 2 steroid shots from having bronchitis that affected my asthma showed 4 lb weight gain literally overnight! Tried not to panic. It came off but it was definite set back in overall weight loss. Nothing I could do but just keep moving forward.

My allergic reaction consists of itching of my mouth, lips, gums and for strawberries my throat swells up bt only for strawberries. Also could u imagine never being able to eat any fruit ever again?? I have a 5yr old so when im cutting his fruit i sometimes take a bite or slice and have a slight 1 minute reation. So its not that im eating a full apple or anything. Also i wasnt always allergic these allergies developed over time. It started with an orange and then everytime i ate a fruit i would discover it over the years as i went along until i realized its all fruit. I just put that in there to say pre-op my body was able to tolerate them now just smelling fruit will make me nauseous or vomit smh. Also its not only corn its mostly every vegetable its very weird to me. For example when i was pre-op i didnt like evry vegetable, but i was able to force myself to eat salads and a lot of things that didnt taste good at all to me because i knew it was healthy. Now if i would dare try to do anything like that i ruin my meal. Many times i will buy a sandwich or be out to eat and ill be okay and 5 mins later my body will reject food. And because of this i went to snacks which are no good because theyre "slider" foods which also contribued to my weight gain.

hi all i am only about 50 or 60 lbs overweight but with the new fda approval for people in my weight range, i decided to do the surgery. had it on 3/15/11 [edited date] and am just having a lot of chest pain (not worried it's heart problems). after hearing so many horror stories about lap bands (and an equal number of positive stories) i feel like it's just a crapshoot. you do the surgery and just hope and pray that you won't have any problems. the other thing is that my insurance wouldn't cover it so i had to pay $16k cash for this. losing the weight is worth that much to me. i wasn't able to lose it because i took antidepressants for a long time which caused the weight gain to begin with but i believe altered my metabolism. i just have so much anxiety today about the chest pain. i called the dr's office and spoke to a nurse who said it's gas, because it comes and goes. but i'm not so sure. i'm just worried that it might be posisitoned wrong. i don't think i could go through another surgery. it was tough. ugh, i just feel like a made a mistake by doing this. would love to hear from some people who maybe had some problems or concerns early and things passed. appreciate it. pam

I too was a bander at one time. I worked in a hospital and there were 5 of us who got it including my husband. In the beginning we all had success, however, for me it was short lived. I only lost 24 lbs and gained almost 50 back. After a few years my restriction was getting worse and I decided to look into the revision. I found out several things...my band was placed too high (by a different surgeon), when he sutured the band to my stomach the sutures punctured my stomach in two places, and my band was ulcerated. I had to first get my band removed to allow the ulcer and my stomach heal and then three months later went back for the sleeve. My husband established care with a surgeon a few weeks ago only to find out that his band was "too tight." Which resulted in weight gain from almost two years of eating slider foods. As for the other 3 women who had the band in 2009 and 2010 when we did, NONE of them are happy with their bands and two are looking into revision now that they've seen my success. Yes, the band was the craze several years ago, however, the surgeon who did my sleeve...his practice is no longer doing them because of all the complications and failure rates. Also, the sleeve is not as "new" as some believe. Back when the bypass began 20 plus years ago, they used to do the sleeve on super obese patients as a first surgery to get their weight down to minimize the risks of the bypass surgery. A lot of these patients lost so much weight and never bothered going back for the second part of the surgery. If you look under anniversaries...a few weeks ago I seen someone celebrating her 20th year post op. It's believed that the sleeve will have better ratings than the bypass, but since it hasn't been an exclusive surgery as long as the bypass it will take several years for the statistics to show it. As for your SIL, the sleeve is very different than the band and she will be thrilled with the success compared to the lack of with the band!

I've been on Cymbalta for years. I have tried 3 times to get off of it - - just can't. I works great for my pain. I didn't really have weight gain from it. I did from other meds and issues (broken leg, chronic fatigue, chronic pain, essential tremor disease and on and on)

How long before you were able to kick BP Meds to the curb? I have been on them about 10 years and have had some really low readings at times since surgery. I also suspect they create a little weight gain. Looking forward to being off these in the near future!

Maybe the plus size clothing allows more room for weight gain and weight loss. For example, I'm wearing a size 22/24 and weigh 326. I'm just barely wearing that size, but refuse to buy 26/28 since I'm getting banned in December. However, I wore a size 22/24 (they were baggy) three years ago when I weighed 270. So, I know that I probably won't get to the coveted 18/20 size until I'm under 270 and that's okay. Bottom line, I think people who are in smaller sizes can drop a size just by losing 10-15 pounds. But, it takes more weight loss for the bigger sizes. Barb

Hi Everyone, Today is my two year bandiversary!!!! I was hoping to be at goal today but I had a very long plateau and a slight weight gain due to the fact that I quit smoking in preparation of plastic surgery in August. So now I have six weeks to get to the 170's!!! There are lots of things I want to share, but many of been said by other tenured bandsters here on this board. The most important change in my life is that I can do most anything!!! I fly airplanes regularly, go to theme parks and do all the coasters, go to Water parks, play with my kids and chase them around and I have lots of energy!!! Plastic surgery is the last part of my journey and then I need to maintain my losses. The one thing I have found is that if you really want to gain weight with the band, it is quite easy to do so. No matter how long you are banded, you have to stick to the plan. meat and fish first, then veggies and last carbs if there is any room left. And exercise is so important. No matter how big you are, it is possible to get exercise if you really want to do it. NO EXCUSES!!! LOL SO today for my second bandiversary, I am going to see my plastic surgeon to finalize all of the details of the procedures that he will be doing tag team with another plastic surgeon. I am having an abdominoplasty, medial thighplasty, breast augmentation with implants to help my saggy boobs! I am excited, but also nervous. It is anticipated that my surgeon will remove about 14 lbs of excess from my stomach and thighs. Yucchhh! But hopefully the results will be worth the pain!! I am scheduled for transformation on august 3rd. I changed the date from June 15th cause I am moving, packing and in the process of building a new house, so the June date didnt work. I want to thank everyone who has offered me great advice over the last two years!!!! Babs in TX 334/18-/170 -154 6/23/03 :rolleyes :laugh :rambo