I am furious with my surgeon at the moment... This is NOT my fault!

[Daydra 345]

Thank you everyone for your time, thought, and responses. I do appreciate the input.

I will respond to each comment, but I think I may need to clarify the intent of my post, as I think that my post (or the intent) may have been misunderstood by some (easy, since it was horrifyingly long...), or perhaps I misunderstood the intent of some of the responses.

I posted this simply to put my experience out there. In doing so, I am hopeful that it might somehow be of use to someone out there. Maybe someone has had a painful experience with their doctor, but doesn't have the confidence (or whatever) to be upset on their own behalf and believe that he/she is the only expert on his/her body and experiences. We can never really guess how what we share might help someone else. At any rate, the two things I wasn't doing, was complaining about a perceived insufficient weight loss, or asking for help.

[Daydra 345]

I read your post and kind if wonder why you arent just working your program and getting healthy !!

Your body just went through major surgery, it takes time to heal, time to stabilize and you are basically ignoring the advice of a professional whom you chose, who hopefully has a proven track record of success, and has a lot more experience at this process than you?

You have been given a chance to restart your life again, at least in terms of nutrition and possibly body weight.

Sorry sent it before i was done.

Since you have this wonderful opportunity to restart, why are you basing your diet/nutrition on your old philosophies that really only assisted you enough to maintain a weight that you felt the need to have WLS?

Work the program, lose some weight, get healthier. You will have plenty of time to figure out your diet as you go,

This isnt meant to be a flame... I just think you are wasting a great opportunity to improve your health...

Thank you, I didn't take it as a flame, but I think we're kind of missing each other here.

I am, actually, following my prescribed calorie and Protein intake guidelines from my clinic's nutritionist. I'm right in the window of where I was advised to be. I'm only just starting to exercise again, the previous calorie far below what I was advised should be my minimum intake left me in an intolerably low-energy state. After nearly 5 weeks in the prescribed intake window, I can finally function mostly normally, but I still have a lot of muscle weakness and need to begin to rebuild strength.

My surgeon is an excellent surgeon. I would trust her to cut me again. She saved the life of one of my coworkers when she overrode a decision made by one of the other surgeons in the office. However, that doesn't necessarily mean that she and I can effectively work together. After this interaction, it is apparent that she is not someone that can partner with me to problem solve with some of the more nuanced aspects of the process. My post was an expression of my hurt, anger, and frustration at this interaction with her. I expressed a concern, and instead of discussing it with me, she immediately decided that I was merely non compliant and must be lying about my nutrition stats. She prevented me (by frequently cutting me off mid-sentence) from completely expressing my concern and my thoughts about it, or fully answering even a single one of her questions. I don't care how much experience she has. I can not have that as a "partner" in my healthcare decisions. There are other professionals out there that are just as experienced.

As far as my "old philosophies" go, using my philosophies and my measurements, I was able to lose 115 pounds between 2009 and 2011. I feel like I can confidently consider that success. I only began to gain weight again when the maintenance of those strategies began to require more effort than I was capable of. I only know that I could maintain at 2400 cal because of 4 years of monitoring. That is certainly no indication that my system didn't work, just that I couldn't maintain it forever. I decided to have the surgery because I was struggling to pull it back together again and was terrified I was going to see 349 again before I managed it. Not to mention being at significant risk for having to go through that all over again, perhaps multiple times throughout the rest of my life. That possibility was untenable. I felt that the surgery would be a significant factor in my equation for long-term success. My life never stopped, so there wasn't really any restart to consider. My health has always been reasonably good and I have 8 triathlon completion medals. As far as the health part of the equation goes, my biggest concern was my health as I age.

The last thing I'll say is that no one is an expert on me, but me. I can totally own when I'm wrong, but not to be considered to have any valuable input on decisions that concern my healthcare and to be expected to accept everything my doctor says without question is not something I will accept.

[Daydra 345]

Hi Daydra, I totally "feel" you. I agree with your assessment as you described, and have had some similar issues due to yo yo dieting/binging for years and my age slowing down weight loss. One thing I wanted to mention is that surgeons become surgeons because they like to go for the quick fix. I don't think many surgeons are interested in exploring other options as to why a body isn't functioning optimally. It sounds to me that you are your best resource. An endocrinologist is helpful to order and interpret hormonal tests, but again I don't see them giving you the answers and guidance you are looking for. I did see a kinesiologist who was also a holistic practitioner and he really knew his stuff. Over the years I have used both western and eastern type practitioners, and have found the eastern type to be much more whole body oriented. Western medicine has become more specialty oriented, to the great detriment of the patient in my opinion. Good luck to you, and keep posting how your Quest is going. I am very interested in hearing how you do and what you find out.

Thank you for the support. Yeah, I really don't expect to get a "complete" answer from any one source. I think each discipline has a piece of the puzzle. I just need to collect those pieces and put them together. What I'm really looking for at this point is to understand exactly what is happening at this time, whether normal or slightly off. That's not really something I can get from a research paper or a diet book, so I'll continue to read to get some background, but if I still need to find out what's happening with me, particularly, I'll need testing. You are so right. We have a long way to go to get to a place where the majority of medical professionals in this country consider the patient as a whole and not a list of discrete ailments that have to fit in 15 minute chunks of time...

The complete disregard was the worst. I felt crushed. This is the kind of crap I gave up $500/mo of Health Reimbursement Arrangement contributions to get health insurance at work so I didn't have to deal with this kind of discrimination in the military treatment facilities I had access to as a dependent. Of any medical specialty, this should have been the one place I didn't have to worry about this kind of thing. The good news is I can schedule further followups with the nurse or with one of the other surgeons if necessary, and now that I'm not experiencing nausea and major fatigue or other side effects, I can do many of my monthly followups over the phone.

[Daydra 345]

I read the beginning of your post and then skimmed the rest since it's long and I'm tired.

Back in high school, I was an avid Water faster. I have gone 14+ days on Water alone. I am not justifying what your surgeon said at all, but just know that it is possible to not eat anything and not end up in the ER. Also, if you jumped right back up from under 700 calories to 1100, your body will gain. Had you taken a more gradual increase of say 100 cals per day, it would not have come back so quickly.

I'm sure that everything will level off for you and you will be okay. You seem to be on track other than this small bump, and you will fall back in place quickly.

Thanks, and no worries on skimming. I totally can't blame you!

I totally agree that you can go for quite some time without food. I believe in general its up to 3 days without water and 21 days without food. However, in my case, I had been eating below what my nutritionist had given me as a caloric floor for around 9 weeks. (pre-op diet, then recovery, then nausea) At any rate, the result was near-passing out and fatigue to such a degree that I could not function. I was managing to make it to and from work at least some days each week, but I couldn't manage to get out into the field to do inspections, so I was stuck in the office with my fieldwork backing up. I'd pass out the instant I got home and would sleep between 14 and 20 hours a day on the weekends, which dropped my intake even further. Both times I had to go into the clinic or the ER, were Mondays after a weekend like that.

Thank you, I know it will stabilize. I feel much better physically, and I am collecting lots of info and have a plan, so it's going to be all good. My current working hypothesis on what's going on is that while I was not clinically dehydrated (Lab tests at the ER show the specific gravity of my urine to be just this side of clinical dehydration. No freaking way is anyone going to get me to believe that not needing to pee when you wake up in the morning and literally never feeling like you need to pee during the day is okay.), the 2 liters of Fluid I received coupled with being better able to hydrate myself after getting better anti-nausea meds and the ability to eat again actually popped me up to the weight I "should" have been, had everything gone more smoothly. I only had a "net" loss of about 1/2 a pound from the morning before I got fluids and meds, but if I count from the weight I topped at a few days later, I think it's about 10 pounds (well, 10 pounds from my appointment on Thursday, now it's more like 12). Unfortunately, my doctor never let me get that far, she just went straight into the non-compliant patient routine. Regardless, I'm still down 45 pounds since July 15. I'm not at all dissatisfied with my overall loss. I only wanted to discuss the concern and bounce my thoughts off her. I'm totally floored that something that should have been so simple turned into such a debacle.

[Daydra 345]

Jeez I read that whole thing.

Whatever else you do, get your BMR tested. That's the one thing you mentioned that makes sense. With that information you do not have to guess any longer. Your BMR test results will tell you exactly how many calories you're burning.

The problem with the fit bit/body bug devices is they estimate your calorie burn based in non sleever information. Everything changed the day you got sleeved. It has been well documented the metabolic "reset" that VSG causes....and they are still not 100% sure how and why. But such things as diabetics being able to go off meds immediately even before they lose the weight...these instances happen frequently.

Point is what worked before sleeve doesn't necessarily work the same way now. Also, curious about your hospitalization. Was it lack of calories or lack of hydration? Cause most people suffer from dehydration immediately after surgery, but lack of calories does not usually cause problems. Our bodies will happily burn fat at that point. But even drinking the 64 oz of Water maynot be enough for someone like you with a large athletic frame. It's not for me. I drink double that. It's always a shock to people how much of our daily Water needs are obtained through food prior to surgery. After surgery, that's no longer the case which is why they push us to drink so much.

Thanks, and yeah, bmr testing is definitely in my plan, even though I believe that this isn't truly the issue (I wrote my working hypothesis in my previous post, I'm sure everyone will appreciate if I don't type it again...)

I could have been way more clear on the hospital visit. I had nausea. No vomiting. I was only getting around 20 oz most days in addition to very low calorie/nutrition. I was reaching the point where I was having near misses with passing out, fatigue, little strength, didn't feel like I could do much other than sleep, frequently light-headed. My biggest fear was that I was dangerously dehydrated and thought that was what was causing the nausea and everything else. My surgeons biggest concern was that I had an abscess or something causing the nausea. Turns out, not clinically dehydrated and after surgeon got test results she stated that she felt that the nausea was due to residual swelling and everything else was because I wasn't getting enough calories. I was forcing enough Protein by sheer force of will with Protein supplements and what I could manage to get down. So, technically, the reason for the trip to the er was the nausea/fear of dehydration, but had it gone on much longer, I would eventually have passed out and ended up there anyway.

Still not getting enough water, but doing much better than I was, and you are right. If you go by the 1 oz for every 2 pounds of body weight, I should be getting in 120 oz. I'm nowhere close to that, but considering at about 20 oz a day I still wasn't clinically dehydrated, so I don't worry about it and just get what I can for now.

As far as the body monitors go, I agree that the devices are powered by algorithms based on averages. However, the bodybugg/bodymedia devices factor a lot more into the calculations than the simpler devices like the fit bit and others that only measure movement. The bodymedia devices are not only triple axis accelerometers, but they also measure skin temperature, heat dissipation, and conductivity, so it "knows" when you are sweating. Also, it's worn on the upper arm instead of the wrist, so it gets a more accurate picture of movement.

For the metabolic changes after surgery, there are tons of papers on improvements in the function of several metabolic hormones (insulin, PYY, GLP-1, etc.), but I haven't run across anything about a dramatic shift in overall calorie burn immediately after surgery, other than the reduction in Total Expended Energy that comes with every calorie restricted "diet". If you have a source for a paper on that, I would really appreciate it if you could send me a link or something. This would be exactly the kind of thing I would like to read. At this point, I just simply haven't come across anything that would lead me to believe that it would be appropriate to expect that still being at 240, I would only be able to lose weight if I ate 40% or less of what I could eat to maintain only 90 days ago.

Thanks again for taking the time to read and respond. I have always thought you give valuable and considered input.

[Daydra 345]

unrelated to your weight and weightloss. Consider working with a more supportive team. I know I do better when I see my struggle as a poartnership with the professionals, and I would not feel so with this one...

Thank you. Agreed!

[Daydra 345]

You are basing your research on the fact that you have gained weight as a consequence of increasing caloric intake. This makes perfect sense, however we all know that our VSG journey is by no means a journey without obstacles, stalls and hiccups along the way. It could be possible that your body is just holding on to some extra calories as a consequence of your calories being too low or it could be some type of stall that has coincided with change in diet. I have been struggling with stalls each time I increase exercise. Unfortunately this journey is different for everyone and even the most prudent surgeons struggle to provide individualized advice. I am 5"1 and my doc has suggested that I shouldn't eat more than 900 cals per day (from now to eternity). Had I consumed the same calories without surgery I dare say that I would have been bordering on an eating disorder. As the others have mentioned - this surgery changes everything. Just be patient, maybe you just need to tweak a few things here and there. My best advice would be to follow your program - stop when you are full and don't eat outside designated Snacks and meals. I hope that helps and I really understand your frustration.

Thank you, I appreciate it. You are absolutely right, I could be having multiple little things going on right now. A stall is certainly possible, as is my body reacting to the "famine" it experienced, as well as the increased ability to hydrate. Could be one, all, or none of these things. I find the diet recommendations between programs to vary so much that it is nearly impossible to implicitly trust any of them. My nutritionist advised me to NEVER eat less than 900 cal. once I made it out of the recovery phase. Eating disorder... Exactly! I did not enjoy my time as an unwilling anorexic and I do not plan to put myself in that situation again. It was not a good time. Yeesh! I would have liked to have told my surgeon that, but she didn't take well to being challenged by questions, I'm pretty sure snarky comments would have gotten me nowhere... :-)

[Daydra 345]

Okay, thanks for the otter babies (WAY too cute and my daughter loves them so I will share with her.)

Yep, your metabolism has been altered by having surgery and while I don't pretend to understand the science behind it, I realize that I will be eating lower calories for probably the rest of my life unless I want to gain weight. I have experimented with calories from the very beginning and my surgeon is like "why are you counting calories...just count Protein grams, that is all I care about" which I understand and appreciate. BUT most of his patients are coming from a lifetime of frustration when it comes to the word CALORIE. So they are fed up with counting calories and I think he tries to provide an easy system to help them keep track but not obsess over calories.

I think part of your frustration is the way you were treated by your dr. I think that would irritate me too. Don't talk to me like I'm a 2 year old who needs a time out. BUT, on the other hand, I sense that another piece of your frustration is the fact that you aren't shedding pounds. I'm not exactly clear about why you were taken to the ER, usually as Butter said, low calorie doesn't equal a trip to the ER, your body just happily burns your excess stored fat. So you thought it was dehydration but wasn't? Usually the dehydration DOES equal a trip to the ER. Anyway, sorry if I didn't catch exactly what happened there. But after the ER you gained +10lbs and have slowly chipped away at that which brings you to the present where you are net -2lbs after the ER +10 GAIN?

Mentally we ALL KNOW that we aren't going to lose weight overnight, but in all honesty who here DOESN'T want the extra pounds gone immediately? I knew going into this that it would be a journey, I knew all my extra weight wouldn't immediately disappear but that didn't stop me from wanting it too. Please give yourself time and take a breather. Your body is still in healing mode. You are not quite 3 months out from major surgery, sounds like you had a hiccup (ER complication) and now you just need to mentally and physically hit the RESET button and work from where you ARE to where you want to BE.

Hang in there!

Thank you! I'm glad I added that little otter payoff :-)

Yes, the extreme frustration and the reason for the post was the treatment by my surgeon. There is going to be some part of me that is always going to "wish" I lost a little more this week/month/whatever, but that part of the equation is so minor, I never would have posted about that. (I save that kind of frustration for my status :-) Also, I'm very realistic about it and actually don't want to lose too fast, because my biggest fear is slowing down my metabolism more than absolutely necessary. Though I know I can't actually control that, slow, steady, and cautious is my goal here (as it is with most things).

"Net" referred to only being 1/2 a pound down from the morning I went to the ER on the day I had my run-in with the surgeon. So the gain of the approximate 10 pounds after treatment was essentially erased. If I counted the ten pounds as lost weight, it would be just about dead on with my calculated caloric deficit over the 4 weeks. So what it would have been nice to be able to get answers to during my appointment is why the gain and does it count? Frustrating that I had to go through the gain and then loss, sure, but gaining after a Fluid infusion was familiar to me (came home from surgery 10 pounds heavier than I went in, took a week to get that off, gained several pounds when I got 4 liters at the clinic (2 liters, 2 days in a row) when we discovered I had a kink in my staple line and we did an endoscopy to straighten it out), so I wasn't concerned so much about the gain itself, just that it didn't come back off within a week -10 days like the previous times I received fluids was making me a bit nervous that something wasn't quite right. (still, none of my testing revealed clinical dehydration, pretty much they gave me fluids to make me "feel" better)

I think I answered the rest of your questions in other replies, but let me know if I missed something.

Thanks again for reading and understanding! I hoped your daughter liked the pictures! (I really gotta find me one of them baby otters!!!)

[Daydra 345]

Oh! and I'm totally okay with eating less calories than before. That was obviously expected. I'm just not okay with 800 cal/day, particularly when I still weigh 240. Extra particularly if I'm gearing up to start training to race again. I was burning nearly 5000 calories on brick or long ride training days. After my previous experience, I just don't see that working out very well... Even at a reduced rate of burn due to lower weight and the associated disproportionate decrease in total expended energy from low cal diets. Although, I will be logging longer distances now that I'm lighter. There will be some trade-off there, but it won't be equal.

[Daydra 345]

It's my thought that you are working yourself up into a frustrated fury and while it's understandable emotionally, it's a tad premature.

You lost a ton of weight pre-op and that's going to slow your weight loss after. You are also approaching that three month stall period. I "only" lost 20 pounds pre-op and I hit my three month stall at about 2.5 months. It lasted 28 days and in that time I fluctuated up and down by about 5 pounds. In that month, I lost 3 pounds but my body size continued to shrink. I ran a few 5ks, hiked a LOT, got in ton of kickboxing and martial arts classes and added calories, decreased calories, starved, gorged... My body did what it wanted WHEN it wanted.

Like you, I tallied everything; calories consumed, estimated calories burned, carbs, fat, miles, steps. There was no reason that I was in a stall other than that I was.

As much as I love science and math (I was a math/sci teacher!), it's not always that cut and dry. Stress will cause you to gain weight or hold on to what you have. I suggest you just keep doing what you are doing, exercise comfortably, eat what is healthy and makes you feel "right" and tough it out. The scale will move in it's own time. You've accomplished GREAT things so far, you will get to where you want to be, I have no doubt.

Thank you! And I agree with everything you said, except, it's not the weight or loss or gain that's got me worked up, it's the interaction with the doctor. Also, I set my start weight in my profile as my high weight in 2009 because I wan't to see all of my hard work indicated there. So it was waaay pre-op. My bmi at surgery was right at 40, and I knew that because I didn't have quite so far to go "only" 100 pounds-ish, I would be unlikely to post huge numbers in tiny amounts of time. That was actually what I wanted, though, because I wanted to be as gentle to my system as I could. Toward the end of my post, the "throwing everything I had" at a problem talk is easily interpreted as me indicating that I was very upset about the weight part, but actually, it's kind of me throwing a bit of a temper tantrum in response to my doc (I'll show you! I'll fix it myself!), and actually has little to do with the actual "problem". I do intend to get my bmr tested, though, because I really want to know. I'd really like to compare it to what I'm getting from my monitor. (that'll be an expensive calibration test...) :-) Not too proud of the tantrum, but I'll own it...

Thank you so much! Hope you have a good day! (one of these hours, I'll actually go to bed...)

[Daydra 345]

Hang in there, Daydra! Definitely get your BMR tested and maybe even a full blood work up to see what's going on. I hope your PCP is patient, kind, and interested so that you can get some peace of mind during this frustrating time. Good luck!

Thank you so much! Good advice and I intend to take it!

[Daydra 345]

Hey there,

For whatever it's worth, I have two thoughts:

1) Give yourself a bit more time to have everything stabilize - you've really been through the mill lately, and it may just take a little longer to get back on track.

2) It sounds as though your surgeon isn't going to be a good partner for figuring out the ins and outs of whatever is going on; now that the surgery is finished, could you maybe just meet with the NUT and only see the surgeon for whatever post-ops are absolutely required? Personally, if I had had that interaction, I'd be shopping for a new doc.

Hang in there - things will get better!!

Thank you! This is exactly where I'm at! Really, none of the post ops are "required". Lots of patients never come back once they're sure they're fine. I've had just enough go wrong that I hadn't felt it appropriate to lose touch with them, but I had no idea that I was going to have this kind of interaction with my surgeon. Fortunately, the weirdness seems to be petering out, and I can always see the nurse or do my post ops by phone unless something else goes wrong (Nothing to see here, Murphy, no jinx to be had here!), so it's no big deal at this point. I just know who I won't go to for certain questions... I haven't decided whether or not there would be any benefit to providing some feedback to her on that interaction. I can't imagine what that would have been like for someone that is more sensitive to conflict than I am. I can just picture someone bursting into tears after that. It really was a mess. I don't even talk to people that way when they're trying to argue their way out of me writing them a ticket, and I'm doing code enforcement work, not a medical provider for people that have had to live a lifetime of discrimination, dismissal, and being stereotyped. Ugh... still angry. I'd better wait a little longer on deciding on that feedback... :-)

[Daydra 345]

Wow..I read your post and all the replies......Well some Doctors are in it for money others are in it because it is their baby and they want to really help people who struggle with the disease. I found one that is very emotional about the whole thing and watches his patients like a worried father...That said..If you are not getting the support you need, go elsewhere!

Stop weighing yourself so much....I know you are an athlete but you still need to nurture your body. I worry about metabolism slowing down with less caloric intake....Being active is amazing and your a full fledged exerciser....Keep your mind on what you feel like...How your clothes fit and the fact that you are moving forward whether fast or slow. You are moving!

All the technical jabber is fine..But you know your body and are learning more and more about it every day....

I was at a surgeons office the other day and he said sorry..I don't know what WLS is.. I have never heard of it...dah!!! That is a man that would never understand anything related to the struggles we go through.....Right now you are struggling within yourself....

Remember that this is a lifetime journey and there will be gains and loses and stalls and what ever else the body can throw at us....

I weigh myself very seldom..Have not experienced a stall or gain yet...I have missed them all because I go by how I feel and the clothes sizes dropping...Our minds are set on numbers... Numbers mean nothing! How you feel, how you look. What are you able to accomplish...How your health is...Those are the priorities....

Over thinking is just that sometimes...Over thinking! Hope some of this makes sense! Always willing to hear your thoughts

Thank you, I appreciate it! I definitely do overthink... everything!!! I am constantly recalculating plans and responses in my head at every turn for whatever I'm dealing with, weight loss included. It has served me well in most cases, but I'm sure I could have benefitted from not trying to control things so much, and I'm sure when action was required, I would still have made good decisions.

Unbelievable that a surgeon (not just a general practitioner, but a surgeon) wouldn't have kept up at least on bariatric surgery in general... Good grief!

[Madam Reverie 2,958]

To be blunt and to not waste anyones time.. Asking a surgeon for a detailed response about the effects of bariatric surgery on an individuals metabolic rate (particularly as we're all different) is like asking a baker to fix a rare sports car. In short, you need an endocrinologist.

As for the impeded weight loss. You sadly had a bit of a rough trot of it immediately after your surgery - so this would definitely have short-circuited the system - giving much credence to the points made by our learned friends on this site, that you may have to wait it out and see how your body normalises.

As far as references for current academic research go, please see below. As you'll know, academic research is normally very narrow in its focus, so you'll have to go through quite a few of them in order to assimilate a potential 'ground truth' for yourself. However, there are some articles which offer the generic information you seek which might at least allay your current fears. Naturally, this comes with the caveat that without full knowledge of the endless subtleties and nuances the endocrine system plays on our bodies, it might appear attractive to propose one hypothesis for your current predicament, for it to then be incorrect because of a previously unidentified and unevaluated interaction.

Consequently, if you want your rare sports car fixed? Go see a specialist mechanic

Hope this helps. Any questions or queries, please do not hesitate to ask. Best of luck, Daydra x

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Nutrition, Metabolism and Cardiovascular Diseases, Volume 19, Issue 3, March 2009, Pages 198-204

F. Frige', M. Laneri, A. Veronelli, F. Folli, M. Paganelli, P. Vedani, M. Marchi, D. Noe', P. Ventura, E. Opocher, A.E. Pontiroli

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7 American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice for the Perioperative Nutritional, Metabolic, and Nonsurgical Support of the Bariatric Surgery Patient Review Article

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9 Bariatric surgery and the gut-brain communication—The state of the art three years later Review Article

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Maria de Fátima Haueisen S. Diniz, Valéria M. Azeredo Passos, Marco Túlio C. Diniz

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10 Postoperative Metabolic and Nutritional Complications of Bariatric Surgery Review Article

Gastroenterology Clinics of North America, Volume 39, Issue 1, March 2010, Pages 109-124

Timothy R. Koch, Frederick C. Finelli

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Bariatric surgery

has become an increasingly important method for management of medically complicated obesity. In patients who have undergone

bariatric surgery

, up to 87% with type 2 diabetes mellitus develop improvement or resolution of their disease postoperatively.

Bariatric surgery

can reduce the number of absorbed calories through performance of either a restrictive or a malabsorptive procedure. Patients who have undergone

bariatric surgery

require indefinite, regular follow-up care by physicians who need to follow laboratory parameters of macronutrient as well as micronutrient malnutrition. Physicians who care for patients after

bariatric surgery

need to be familiar with common postoperative syndromes that result from specific nutrient deficiencies.

11 Update: Metabolic and Cardiovascular Consequences of Bariatric Surgery Review Article

Endocrinology and Metabolism Clinics of North America, Volume 40, Issue 1, March 2011, Pages 81-96

Donald W. Richardson, Mary Elizabeth Mason, Aaron I. Vinik

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Obesity is a disease state with polygenic inheritance, the phenotypic penetrance of which has been greatly expanded by the attributes of modern civilization. More than two-thirds of obese persons have comorbidities, many of which are characteristic of cardiometabolic risk syndrome (CMRS) in addition to other life-quality–reducing complaints. The CMRS is associated with increased cardiovascular events and mortality. Individuals with a body mass index greater than 35 infrequently achieve or maintain weight loss adequate to resolve these metabolic and anatomic issues by lifestyle or pharmacologic strategies. Data suggest that some of these patients may be better served by

bariatric surgery

.

12 Secretion and Function of Gastrointestinal Hormones after Bariatric Surgery: Their Role in Type 2 Diabetes Review Article

Canadian Journal of Diabetes, Volume 35, Issue 2, 2011, Pages 115-122

Alpana Shukla, Francesco Rubino

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13 Cirurgia bariátrica: como e por que suplementar Review Article

Revista da Associação Médica Brasileira, Volume 57, Issue 1, January–February 2011, Pages 113-120

Livia Azevedo Bordalo, Tatiana Fiche Sales Teixeira, Josefina Bressan, Denise Machado Mourão

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14 Tratamiento quirúrgico de la obesidad: recomendaciones prácticas basadas en la evidencia Original Research Article

Endocrinología y Nutrición, Volume 55, Supplement 3, March 2008, Pages 1-24

M. José Morales, M. Jesús Díaz-Fernández, Assumpta Caixàs, Albert Goday, José Moreiro, Juan José Arrizabalaga, Alfonso Calañas-Continente, Guillem Cuatrecasas, Pedro Pablo García-Luna, Lluís Masmiquel, Susana Monereo, Basilio Moreno, Wilfredo Ricart, Josep Vidal, Fernando Cordido

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15 Micronutrient deficiencies after bariatric surgery Review Article

Nutrition, Volume 26, Issues 11–12, November–December 2010, Pages 1031-1037

Padmini Shankar, Mallory Boylan, Krishnan Sriram

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16 Xeroftalmía bilateral por déficit de vitamina A secundario a cirugía bariátrica

Endocrinología y Nutrición, Volume 54, Issue 7, August 2007, Pages 398-401

Beatriz Alonso Castañeda, María Ángeles Valero Zanuy, Paula Soriano Perera, Francisco García Ruiz, Roberto López Lancho, Susana Perucho Martínez

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17 Metabolic surgery and gut hormones – A review of bariatric entero-humoral modulation Review Article

Physiology & Behavior, Volume 97, Issue 5, 14 July 2009, Pages 620-631

Hutan Ashrafian, Carel W. le Roux

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18 Bariatric surgery in duodenal switch procedure: weight changes and associated nutritional deficiencies Original Research Article

Endocrinología y Nutrición (English Edition), Volume 58, Issue 5, 2011, Pages 214-218

Francisco Botella Romero, Marta Milla Tobarra, José Joaquín Alfaro Martínez, Llanos García Arce, Angélica García Gómez, M. Ángeles Salas Sáiz, Antonio Soler Marín

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19 Alteraciones del metabolismo óseo en la cirugía bariátrica Review Article

Medicina Clínica, Volume 136, Issue 5, 26 February 2011, Pages 215-221

Virginia Ruiz-Esquide, Pilar Peris, Laia Gifre, Nuria Guañabens

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20 Bariatric surgery in patients with late-stage type 2 diabetes: expected beneficial effects on risk ratio and outcomes Original Research Article

Diabetes & Metabolism, Volume 35, Issue 6, Part 2, December 2009, Pages 564-568

E. Renard

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21 Reversible neurologic dysfunction caused by severe Vitamin deficiency after malabsorptive bariatric surgery

Surgery for Obesity and Related Diseases, Volume 2, Issue 6, November–December 2006, Pages 656-660

Michael M. Rothkopf

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22 What can bariatric surgery teach us about the pathophysiology of type 2 diabetes? Original Research Article

Diabetes & Metabolism, Volume 35, Issue 6, Part 2, December 2009, Pages 499-507

F. Andreelli, C. Amouyal, C. Magnan, G. Mithieux

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23 Seasonal changes in serum 25-OH-Vitamin D₃ after bariatric surgery

e-SPEN, the European e-Journal of Clinical Nutrition and Metabolism, Volume 3, Issue 5, October 2008, Pages e208-e210

F. Granado-Lorencio, A. Simal-Antón, I. Blanco-Navarro

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24 Decreased dopamine type 2 receptor availability after bariatric surgery: Preliminary findings Original Research Article

Brain Research, Volume 1350, 2 September 2010, Pages 123-130

Julia P. Dunn, Ronald L. Cowan, Nora D. Volkow, Irene D. Feurer, Rui Li, D. Brandon Williams, Robert M. Kessler, Naji N. Abumrad

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25 Nutritional Deficiencies in Obesity and After Bariatric Surgery Review Article

Pediatric Clinics of North America, Volume 56, Issue 5, October 2009, Pages 1105-1121

Stavra A. Xanthakos

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