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Thank you all for your insight! I double and triple checked with my insurance, even read the medical jargon 14 page breakdown of coverage and requisites for it, and no time threshold was set. They only request proof of continued weight gain with attempts at weight loss, which I have. Here's to hoping that may speed up my process!

This surgery isn't new, it is the first part of a duodenal switch which has been around for a long time. A couple of facts about weight - Men generally have male pattern weight gain which gives them a spare tyre rather than an hour glass shape. After menopause women don't have as much oestogen so they accumulate weight around the middle whearas previously they may have gained it more around the hips. You can't predict or influence where you lose weight - the flat belly diet etc are all a load of hype for the purpose of selling books. It will come off where it wants too. You can influence your shape by targeting muscles in certain areas You can also reshape your body with plastic surgery if you can afford to Most people that are obese or morbidly obese have large stomachs to start with so even after weight has been lost it stands to reason that there will be an accumulation of fat and or loose skin in that area.

How are you today??? I just saw your above post...I say go to another doctor TODAY. No sense in waiting until your Doc returned Monday. What you are describing are reason to be concerned to me. don't wait!!! Maybe it's nothing and we can all laugh with you about it, but to me those symptoms don't sound like 'nothing'. Swelling, rapid weight gain, pain under a rib cage, tenderness and warmth don't sound like no big deal type of symptoms. Please go get it checked out TODAY!!!

sounds about normal to me... the weight gain that is...I actually gain from 10 to 15 pounds here and there, but for some strange reason I lose it all. the depression needs to be addressed... I can see why you get a little down.... we don't want to gain a pound... I'm a 10 year vet. so keep your head up and no matter what keep it moving somehow... good luck

Thanks guys! My doctor is on vacation until Monday. If I gain anymore prior to her return, I am going to the ER. I forgot to mention I am having pain on my right side right under my rib cage when I take deep breaths and can feel it whenever I eat. It's tender to the touch and feels a little warm. I had a HIDA scan to check my gallbladder a few months ago and all was fine..... Would gallbladder issues cause weight gain and swelling? We will see I guess.

definitely get on top of that ASAP. It'll be a lot easier to lose 10 lbs than 50! If you're not still weighing, measuring, and logging your food, I'd start there. do keep in mind, though, that a 10-20 lb rebound weight gain is very common in year 3. It's just your body settling into whatever weight it wants to be. That's not to say you're stuck there - you CAN lose it - but if this your body's new "set point", just be aware that it's going to take some work to get down to - and maintain - a lower weight.

Hello everyone thx for commenting! I will try the shakes. I have done some research on weight gain shakes. so far I have tried whey protien powder, with oatmeal, banana, peanut butter, and whole milk. it was pretty tasty so I will contiune those in between meals and see how that works. @SqueakyWheel&Ethyl thanks for the kind words, my family and friends all say i look great and dont look sickly skinny as I think I do.. you have a hand full of folks that think i lost too much weight but I am sure they have said it to others and not me. I am actually a little smaller than I was in high school and I have always been very curvy (thick or thin) but now I am starting to see the curvy vanish and that's bothering me more than anything. I guess this is why they say it's important to attend support groups and ect after but I have failed to do so. I have also not been taking my vit. like I should and I also stopped drinking the protien shakes. maybe that all played a part in me loosing too much. I have also checked on my BMI and I currently at a normal and healthy weight just struggling to see that in the mirror!

Hi there, hope you're doing well. I don't know what to tell you about your long time of depression. Mine came on in my mid 30's after a a very sad , difficult personal issue. Im usually a very upbeat, outgoing happy person, but depression kicked. my. rear ! Its horrible to be sad, depressed and angry 24/7, add the slowing down metabolism and weight gain, and sleep problems! Well as you know, its NOT pretty... A friend reccommended a product called Plus, from Mannatech. (google Mannatech for more info) I started pounding down Plus 4 pills , 3x a day. 12 days later it was like someone lifted a layer of sadness off of me ! I got better and better, stayed on it = depression gone. Both my husband and I take several Mannatech products daily, what a difference ! ( He' s diabetic, no weight probs). (I am NOT a Dr. so discuss with your Dr before taking taking anything ) Hope this helps, I wish you well ! Keep us posted !

Thank you both. I spoke to a relative regarding the bruising - he's a retired oncologist and hematologist. He thinks it's likely a vitamin K deficiency, but also suggested bloodwork, which I fully intend to request during my physical. He also asked if I take Ibuprofen on a regular basis (which I do due to the aches & pains) and he said that could cause it as well. Hoping that's all it is. As for the brain fog, memory loss, and mood swings, I totally agree that it could be hormones. My biggest concern though is the weight gain. I've worked so hard to get where I am...I got on the scale this morning and I'm up another .5#. I just want to cry.

LOL! That cracked me up about the food police thing. Your right, my family has tried that a few times and they get met with a very insulted look. Considering they are all still gaining weight from eating and drinking whatever they want, I figure at least I'm on the downward trend. If I want to splurge once in awhile they can deal with it. I can't think of a time since being banded where a splurge has ever caused a weight gain. I typically will plateau for several weeks at a time but it stays pretty stable. I don't know how many times I have gone in to weigh thinking I've gained 10 pounds to actually find I've either stayed the same or lost a few pounds. One of the nicest things you could do is rub your partner's back when she gets a stuck feeling. I get a huge cramp when I get stuck and that really feels good. Teresa

I stopped taking it too…. I was advised to stop taking it preop so I never started again. I have to go see my gynecologist next week so, I guess that's one of the questions I should be asking. I'm also not on my birth control pills – that was another thing they want to meet a stop preop i'm not sure if that will affect any weight gain or Water retention or anything of that nature… I'm on a relatively low dose one. But I can definitely feel the sis coming on and feeling them burst. It's not as bad or I should say frequent when I'm on my meds. What are y'all's experience with them?

I've suffered from severe depression since I was 15 years old. I was "normal" weight until I hit 50 and a succession of events contributed to a lot of weight gain. I had RNY and it has not affected my medication at all. Did surgery "cure" my depression? Not at all!! But I am at least physically healthier and can get around better!! One less thing I have to worry about!! My diabetes is gone, my high blood pressure is normal and they fixed my hernia. Don't let anyone tell you what you should do!! Only my son and one sister knows I had the surgery for the very reason that I didn't want the judgement or listen to the negativity!! Good luck!! To thine own self be true!!

If you're taking BC pills you need to continue them for at least 1 year after surgery. The risk is too high to you and the baby if you get pregnant before you lose all of your excess weight. Plus it's very unsafe for a baby to gestate in an overweight mother. While those babies survive just fine, they have many issues as they grow up so it's to your advantage and your future child's advantage for you to get on birth control (no reason to stop taking it 4 weeks before surgery - say on it the entire time - talk to your surgeon about that) and stay on it for at least 12 months following or until you've lost all of your extra weight then about 3 months after you've reached your goal. Once you're at that point you'll know how you should eat. This is crucial because it's very likely you'll have your Fluid mostly - if not completely - removed if/when you become pregnant and if you already know how to eat you'll be able to minimize weight gain outside of the necessary 20-30 lbs for your baby.

I have a little experience with excess skin, lap band and RNY. I was always on the heavy side since childhood and when I was 19 I lost over 100 lbs fairly quickly with the help of drugs that you could get very easily back then but were not done through a prescription. I then gained it back over the course of a year and then the following year lost it again. During those two weight losses I had no extra skin. I then put on about 25lbs became pregnant and had a 9lb11oz baby and stretched out my stomach, gained some weight over a 3 year period and had a 10+lb baby and stretched out my stomach a lot more. So basically even though I lost weight quickly the first two times I had no extra skin and didn't until I had to the two babies. I don't know if it's a quick weight gain then loss that creates the skin, genetics or what but I don't think you can say that with lap band you'll have no extra skin and with RNY you will. I will always have extra skin no matter what. My daughter was a quick gainer of weight prior to her RNY. I think she may have put on an extra 60 lbs fairly quickly at one time so since her surgery she's having extra skin issues and is in her 20s. So maybe it's a quick gain that does it not necessarily a quick loss that guarantees the extra skin or both. Just a thought. It does take more time to recover from RNY as I have been there since my daughter's surgery this past May. There are many more things you have to take in order to supplement your diet basically for the rest of your life. It works, I've heard people can gain back weight after a period of time but not as much as the had lost in the beginning. I personally did have a difficult time letting my daughter go through this as she's my flesh and blood and no one wants their child to go through something this traumatic but then I knew if she didn't she'd be miserable and she chose this surgery over the lap band as she felt it had a better rate of success. I don't know if my issues had that much to do with it as she's a pretty smart cookie and makes up her own mind. Nancy:smile:

sleep apnea is a serious sleep disorder that can cause weight gain beside high blood pressure, heart attack, stroke & diabetes. It doesn't go away with ear plugs. I would be learning everything possible.

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

I was sleeved in May 2014. My top weight was 252 (the day of surgery) and I lost down to 165 in a little over a year’s time. I have since gained weight and am at 220. I’m extremely depressed about it, yet nothing I am doing is helping. I’ve read that some have undergone a re-sleeve after some weight gain and I’m interested in finding anyone who has had this done and if so, has it been successful a 2nd time and who has re-sleeved you? I moved to Iowa three years ago and can’t find anyone who does it. HELP!

Prednisone is quite possibly one of the worst things you could put into your system. When I was a pharmacy tech; we would go out of our way to talk to doctors to find alternatives for it. Perhaps your PCP can give you something else? Besides weight gain, it has some terrible side effects, especially after a procedure like this. What you're experience is quite normal for this medication.

Pckeys, you’ve touched on a real concern I’ve had...”Preserving BMR”. All of my life I’ve heard that weight gain is often a result of repeated very low calorie dieting that translates into a permanently lowered BMR, thus we pack on weight even easier each time. Will this extended sprint of 800 cal months create the same? If so, are we better off consuming 1,000 daily even if we perhaps lose at a slower rate? A question I keep intending to ask surgeon or NUT but have not. Hmmmm.

Weight gain immediately following surgery is quite common and absolutely nothing to worry about. It can and does happen but it won't last. Focus all of your attention on following the protocol to the letter and stay away from the scales for at least a week, two would be even better. You're gonna love the new you!!

Hi All!! In preparation for my plastic surgery consult (and hopefully procedures) this spring I've upped my workouts to try and get into the best possible shape. I hate that even after all of my successes, I still let the number on the scale dictate my moods and my actions. In the past, when I've started working out harder I gave up because the number on the scale actually went UP. Logically, I know this is inflammation, Water retention, possibly not getting enough calories and going into starvation mode...anything but "real" weight gain. BUT, I let it get to me anyway and would stop working out (which of course didn't result in losing a bunch of weight, lol). Currently, I have about 5 more weeks until my consult, and I've just decided to stay OFF the scale. I don't really care what the number is (for the first time in my life I'm happy with my weight) and I know that working out and eating right will get me where I need to be. Right now I'm working out twice per day: waking up at 5am and working out doing either light cardio or strength, and then again when I get home from work, usually more intense cardo training in the evening. So far, I feel great. This is my third week into it...and I haven't given up!! When I go in for my consult in April I'll be looking to do a 360 lower body lift and breast lift. I've gotten some good advise about the lower body lift, and have learned that the better shape your core is in before surgery, the better your recovery will be. I'm going to give it all I've got, and hopefully I'll continue to see positive changes!

Hey Mvpo, I haven't really had any tests yet, they did one test, but according to what I've read, and what my aunt said (she's a doctor) they did the test wrong, so I'm not being treated in any way for the Cushings yet. I didn't know that weight gain was one of the primary, but I"m still learning about it. Not much that I've found, other than one support board that isn't like LBT, and a few other sites that just rehash the NIH site information, or quote it directly. I think being able to maintain any thing has been amazing.

Aha..that is so interesting. Good to hear that it's a natural process when it works. Ive heard all these horror stories about weight gain afterwards. Im still working on my new eating style and trying to get rid of falling back to my old ways.

Really one question and then one statement..I'm feeling kinda down about the weight gain. Some say,oh it's because you're comfortable but know it's me just not taking accountability for stuffing bad things in my mouth

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.