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I ran accross this today. I found it good information for those of us considering/waiting for WlS. Pouch Rules for Dummies INTRODUCTION: A common misunderstanding of gastric bypass surgery is that the pouch causes weight loss because it is so small, the patient eats less. Although that is true for the first six months, that is not how it works. Some doctors have assumed that poor weight loss in some patients is because they aren’t really trying to lose weight. The truth is it may be because they haven’t learned how to get the satisfied feeling of being full to last long enough. HYPOTHESIS OF POUCH FUNCTION: We have four educated guesses as to how the pouch works: 1. Weight loss occurs by actually slightly stretching the pouch with food at each meal or; 2. Weight loss occurs by keeping the pouch tiny through never ever overstuffing or; 3. Weight loss occurs until the pouch gets worn out and regular eating begins or; 4 Weight loss occurs with education on the use of the pouch. PUBLISHED DATA: How does the pouch make you feel full? The nerves tell the brain the pouch is distended and that cuts off hunger with a feeling of fullness. What is the fate of the pouch? Does it enlarge? If it does, is it because the operation was bad, or the patient is overstuffing themselves, or does the pouch actually re-grow in a healing attempt to get back to normal? For ten years, I had patients eat until full with cottage cheese every three months, and report the amount of cottage cheese they were able to eat before feeling full. This gave me an idea of the size of their pouch at three month intervals. I found there was a regular growth in the amount of intake of every single pouch. The average date the pouch stopped growing was two years. After the second year, all pouches stopped growing. Most pouches ended at 6 oz., with some as large at 9-10 ozs. We then compared the weight loss of people with the known pouch size of each person, to see if the pouch size made a difference. In comparing the large pouches to the small pouches, THERE WAS NO DIFFERENCE IN PERCENTAGE OF WEIGHT LOSS AMONG THE PATIENTS. This important fact essentially shows that it is NOT the size of the pouch but how it is used that makes weight loss maintenance possible. OBSERVATIONAL BASED MEDICINE: The information here is taken from surgeon’s “observations” as opposed to “blind” or “double blind” studies, but it IS based on 33 years of physician observation. Due to lack of insurance coverage for WLS, what originally seemed like a serious lack of patients to observe, turned into an advantage as I was able to follow my patients closely. The following are what I found to effect how the pouch works: 1. Getting a sense of fullness is the basis of successful WLS. 2. Success requires that a small pouch is created with a small outlet. 3. Regular meals larger than 1 ½ cups will result in eventual weight gain. 4. Using the thick, hard to stretch part of the stomach in making the pouch is important. 5. By lightly stretching the pouch with each meal, the pouch send signals to the brain that you need no more food. 6. Maintaining that feeling of fullness requires keeping the pouch stretched for awhile. 7. Almost all patients always feel full 24/7 for the first months, then that feeling disappears. 8. Incredible hunger will develop if there is no food or drink for eight hours. 9. After 1 year, heavier food makes the feeling of fullness last longer. 10. By drinking water as much as possible as fast as possible (“water loading”), the patient will get a feeling of fullness that lasts 15-25 minutes. 11. By eating “soft foods” patients will get hungry too soon and be hungry before their next meal, which can cause snacking, thus poor weight loss or weight gain. 12. The patients that follow “the rules of the pouch” lose their extra weight and keep it off. 13. The patients that lose too much weight can maintain their weight by doing the reverse of the “rules of the pouch.” HOW DO WE INTERPRET THESE OBSERVATIONS? POUCH SIZE: By following the “rules of the pouch”, it doesn’t matter what size the pouch ends up. The feeling of fullness with 1 ½ cups of food can be achieved. OUTLET SIZE: Regardless of the outlet size, liquidy foods empty faster than solid foods. High calorie liquids will create weight gain. EARLY PROFOUND SATIETY: Before six months, patients much sip water constantly to get in enough water each day, which causes them to always feel full. After six months, about 2/3 of the pouch has grown larger due to the natural healing process. At this time, the patient can drink 1 cup of water at a time. OPTIMUM MATURE POUCH: The pouch works best when the outlet is not too small or too large and the pouch itself holds about 1 ½ cups at a time. IDEAL MEAL PROCESS (rules of the pouch): 1. The patient must time meals five hours apart or the patient will get too hungry in between. 2. The patient needs to eat finely cut meat and raw or slightly cooked veggies with each meal. 3. The patient must eat the entire meal in 5-15 minutes. A 30-45 minute meal will cause failure. 4. No liquids for 1 ½ hours to 2 hours after each meal. 5. After 1 ½ to 2 hours, begin sipping water and over the next three hours slowly increase water intake. 6. 3 hours after last meal, begin drinking LOTS of water/fluids. 7. 15 minutes before the next meal, drink as much as possible as fast as possible. This is called “water loading.” IF YOU HAVEN’T BEEN DRINKING OVER THE LAST FEW HOURS, THIS ‘WATER LOADING’ WILL NOT WORK. 8. You can water load at any time 2-3 hours before your next meal if you get hungry, which will cause a strong feeling of fullness. THE MANAGEMENT OF PATIENT TEACHING AND TRAINING: You must provide information to the patient pre-operatively regarding the fact that the pouch is only a tool: a tool is something that is used to perform a task but is useless if left on a shelf unused. Practice working with a tool makes the tool more effective. NECESSITY FOR LONG TERM FOLLOW-UP: Trying to practice the “rules of the pouch” before six to 12 months is a waste. Learning how to delay hunger if the patient is never hungry just doesn’t work. The real work of learning the “rules of the pouch” begins after healing has caused hunger to return. PREVENTION OF VOMITING: Vomiting should be prevented as much as possible. Right after surgery, the patient should sip out of 1 oz cups and only 1/3 of that cup at a time until the patient learns the size of his/her pouch to avoid being sick. It is extremely difficult to learn to deal with a small pouch. For the first 6 months, the patient’s mouth will literally be bigger than his/her stomach, which does not exist in any living animal on earth. In the first six weeks the patient should slowly transfer from a liquid diet to a blenderized or soft food diet only, to reduce the chance of vomiting. Vomiting will occur only after eating of solid foods begins. Rice, pasta, granola, etc. will swell in time and overload the pouch, which will cause vomiting. If the patient is having trouble with vomiting, he/she needs to get 1 oz cups and literally eat 1 oz of food at a time and wait a few minutes before eating another 1 oz of food. Stop when “comfortably satisfied,” until the patient learns the size of his/her pouch. SIX WEEKS After six weeks, the patient can move from soft foods to heavy solids. At this time, they should use three or more different types of foods at each sitting. Each bite should be no larger than the size of a pinkie fingernail bed. The patient should choose a different food with each bite to prevent the same solids from lumping together. No liquids 15 minutes before or 1 ½ hours after meals. REASSURANCE OF ADEQUATE NUTRITION By taking vitamins everyday, the patient has no reason to worry about getting enough nutrition. Focus should be on proteins and vegetables at each meal. MEAL SKIPPING Regardless of lack of hunger, patient should eat three meals a day. In the beginning, one half or more of each meal should be protein, until the patient can eat at least two oz of protein at each meal. ARTIFICIAL SWEETENERS In our study, we noticed some patients had intense hunger cravings which stopped when they eliminated artificial sweeteners from their diets. AVOIDING ABSOLUTES Rules are made to be broken. No biggie if the patient drinks with one meal – as long as the patient knows he/she is breaking a rule and will get hungry early. Also if the patient pigs out at a party – that’s OK because before surgery, the patient would have pigged on 3000 to 5000 calories and with the pouch, the patient can only pig on 600-1000 calories max. The patient needs to just get back to the rules and not beat him/herself up. THREE MONTHS At three months, the patient needs to become aware of the calories per gram of different foods to be aware of “the cost” of each gram. (cheddar cheese is 16 cal/gram; peanut butter is 24 cals/gram). As soon as hunger returns between three to six months, begin water loading procedures. THREE PRINCIPLES FOR GAINING AND MAINTAINING SATIETY 1. Fill pouch full quickly at each meal. 2. Stay full by slowing the emptying of the pouch. (Eat solids. No liquids 15 minutes before and none until 1 ½ hours after the meal). A scientific test showed that a meal of egg/toast/milk had almost all emptied out of the pouch after 45 minutes. Without milk, just egg and toast, more than ½ of the meal still remained in the pouch after 1 ½ hours. 3. Protein, protein, protein. Three meals a day. No high calorie liquids. FLUID LOADING Fluid loading is drinking water/liquids as quickly as possible to fill the pouch which provides the feeling of fullness for about 15 to 25 minutes. The patient needs to gulp about 80% of his/her maximum amount of liquid in 15 to 30 SECONDS. Then just take swallows until fullness is reached. The patient will quickly learn his/her maximum tolerance, which is usually between 8-12 oz. Fluid loading works because the roux limb of the intestine swells up, contracting and backing up any future food to come into the pouch. The pouch is very sensitive to this and the feeling of fullness will last much longer than the reality of how long the pouch was actually full. Fluid load before each meal to prevent thirst after the meal as well as to create that feeling of fullness whenever suddenly hungry before meal time. POST PRANDIAL THIRST It is important that the patient be filled with water before his/her next meal as the meal will come with salt and will cause thirst afterwards. Being too thirsty, just like being too hungry will make a patient nauseous. While the pouch is still real small, it won’t make sense to the patient to do this because salt intake will be low, but it is a good habit to get into because it will make all the difference once the pouch begins to regrow. URGENCY The first six months is the fastest, easiest time to lose weight. By the end of the six months, 2/3 of the regrowth of the pouch will have been done. That means that each present day, after surgery you will be satisfied with less calories than you will the very next day. Another way to put it is that every day that you are healing, you will be able to eat more. So exercise as much as you can during that first six months as you will never be able to lose weight as fast as you can during this time. SIX MONTHS Around this time, our patients begin to get hungry between meals. THEY NEED TO BATTLE THE EXTRA SALT INTAKE WITH DRINKING LOTS OF FLUIDS IN THE TWO TO THREE HOURS BEFORE THEIR NEXT MEAL. Their pouch needs to be well watered before they do the last gulping of water as fast as possible to fill the pouch 15 minutes before they eat. INTAKE INFORMATION SHEET AS A TEACHING TOOL I have found that having the patients fill out a quiz every time they visit reminds them of the rules of the pouch and helps to get them “back on track.” Most patients have no problems with the rules, some patients really struggle to follow them and need a lot of support to “get it”, and a small percentage never quite understand these rules, even though they are quite intelligent people. HONEYMOON SYNDROME The lack of hunger and quick weight loss patients have in the first six months sometimes leads them to think they don’t need to exercise as much and can eat treats and extra calories as they still lose weight anyway. We call this the “honeymoon syndrome” and they need to be counseled that this is the only time they will lose this much weight this fast and this easy and not to waste it by losing less than they actually could. If the patient’s weight loss slows in the first six months, remind them of the rules of water intake and encourage them to increase their exercise and drink more water. You can compare their weight loss to a graph showing the average drop of weight if it will help them to get back on track. EXERCISE In addition to exercise helping to increase the weight loss, it is important for the patient to understand that exercise is a natural antidepressant and will help them from falling into a depression cycle. In addition, exercise jacks up their metabolic rate during a time when their metabolism after the shock of surgery tends to want to slow down. THE IDEAL MEAL FOR WEIGHT LOSS The ideal meal is one that is made up of the following: ½ of your meal to be low fat protein, ¼ of your meal low starch vegetables and ¼ of your meal solid fruits. This type of meal will stay in your pouch a long time and is good for your health. VOLUME VS. CALORIES The gastric bypass patient needs to be aware of the length of time it takes to digest different foods and to focus on those that take up the most space and take time to digest so as to stay in the pouch the longest, don’t worry about calories. This is the easiest way to “count your calories.” For example, a regular stomach person could gag down two whole sticks of butter at one sitting and be starved all day long, although they more than have enough calories for the day. But you take the same amount of calories in vegetables, and that same person simply would not be able to eat that much food at three sittings – it would stuff them way too much. ISSUES FOR LONG TERM WEIGHT MAINTENANCE Although everything stated in this report deals with the first year after surgery, it should be a lifestyle that will benefit the gastric bypass patient for years to come, and help keep the extra weight off. COUNTER-INTUITIVENESS OF FLUID MANAGEMENT I admit that avoiding fluids at meal time and then pushing hard to drink fluids between meals is against everything normal in nature and not a natural thing to be doing. Regardless of that fact, it is the best way to stay full the longest between meals and not accidentally create a “soup” in the stomach that is easily digested. SUPPORT GROUPS It is natural for quite a few people to use the rules of the pouch and then to tire of it and stop going by the rules. Others “get it” and adhere to the rules as a way of life to avoid ever regaining extra weight. Having a support group makes all the difference to help those that go astray to be reminded of the importance of the rules of the pouch and to get back on track and keep that extra weight off. Support groups create a “peer pressure” to stick to the rules that the staff at the physician’s office simply can’t create. TEETER TOTTER EFFECT Think of a teeter totter suspended in mid air in front of you. Now on the left end is exercise that you do and the right end is the foods that you eat. The more exercise you do on the left, the less you need to worry about the amount of foods you eat on the right. In exact reverse, the more you worry about the foods you eat and keep it healthy on the right, the less exercise you need on the left. Now if you don’t concern yourself with either side, the higher the teeter totter goes, which is your weight. The more you focus on one side or the other, or even both sides of the teeter totter, the lower it goes, and the less you weigh. TOO MUCH WEIGHT LOSS I have found that about 15% of the patients which exercise well and had between 100 to 150 lbs to lose, begin to lose way too much weight. I encourage them to keep up the exercise (which is great for their health) and to essentially “break the rules” of the pouch. Drink with meals so they can eat snacks between without feeling full and increase their fat content as well take a longer time to eat at meals, thus taking in more calories. A small but significant amount of gastric bypass patients actually go underweight because they have experienced (as all of our patients have experienced) the ravenous hunger after being on a diet with an out of control appetite once the diet is broken. They are afraid of eating again. They don’t “get” that this situation is literally, physically different and that they can control their appetite this time by using the rules of the pouch to eliminate hunger. BARIATRIC MEDICINE A much more common problem is patients who after a year or two plateau at a level above their goal weight and don’t lose as much weight as they want. Be careful that they are not given the “regular” advice given to any average overweight individual. Several small meals or skipping a meal with a liquid protein substitute is not the way to go for gastric bypass patients. They must follow the rules, fill themselves quickly with hard to digest foods, water load between, increase their exercise and the weight should come off much easier than with regular people diets. SUMMARY 1. The patient needs to understand how the new pouch physically works. 2. The patient needs to be able to evaluate their use of the tool, compare it to the ideal and see where they need to make changes. 3. Instruct your patient in all ways (through their eyes with visual aids, ears with lectures and emotions with stories and feelings) not only on how but why they need to learn to use their pouch. The goal is for the patient to become an expert on how to use the pouch. EVALUATION FOR WEIGHT LOSS FAILURE The first thing that needs to be ruled out in patients who regain their weight is how the pouch is set up. 1. the staple line needs to be intact; 2. same with the outlet and; 3. the pouch is reasonably small. 1) Use thick barium to confirm the staple line is intact. If it isn’t, then the food will go into the large stomach, from there into the intestines and the patient will be hungry all the time. Check for a little ulcer at the staple line. A tiny ulcer may occur with no real opening at the line, which can be dealt with as you would any ulcer. Sometimes, though, the ulcer is there because of a break in the staple line. This will cause pain for the patient after the patient has eaten because the food rubs the little opening of the ulcer. If there is a tiny opening at the staple line, then a reoperation must be done to actually separate the pouch and the stomach completely and seal each shut. 2) If the outlet is smaller than 7-8 mill, the patient will have problems eating solid foods and will little by little begin eating only easy-to-digest foods, which we call “soft calorie syndrome.” This causes frequent hunger and grazing, which leads to weight regain. 3) To assess pouch volume, an upper GI doesn’t work as it is a liquid. The cottage cheese test is useful – eating as much cottage cheese as possible in five to 15 minutes to find out how much food the pouch will hold. It shouldn’t be able to hold more than 1 ½ cups in 5 – 15 minutes of quick eating. If everything is intact then there are four problems that it may be: 1) The patient has never been taught the rules; 2) The patient is depressed; 3) The patient has a loss of peer support and eventual forgetting of rules, or 4) The patient simply refuses to follow the rules. LACK OF TEACHING An excellent example is a female patient who is 62 years old. She had the operation when she was 47 years old. She had a total regain of her weight. She stated that she had not seen her surgeon after the six week follow up 15 years ago. She never knew of the rules of the pouch. She had initially lost 50 lbs and then with a commercial weight program lost another 40 lbs. After that, she yo-yoed up and down, each time gaining a little more back. She then developed a disease (with no connection to bariatric surgery) which weakened her muscles, at which time she gained all of her weight back. At the time she came to me, she was treated for her disease, which helped her to begin walking one mile per day. I checked her pouch with barium and the cottage cheese test which showed the pouch to be a small size and that there was no leakage. She was then given the rules of the pouch. She has begun an impressive and continuing weight loss, and is not focused on food as she was, and feeling the best she has felt since the first months after her operation 15 years ago. DEPRESSION Depression is a strong force for stopping weight loss or causing weight gain. A small number of patients, who do well at the beginning, disappear for awhile only to return having gained a lot of weight. It seems that they almost on purpose do exactly opposite of everything they have learned about their pouch: they graze during the day, drink high calorie beverages, drink with meals and stop exercising, even though they know exercise helps stop depression. A 46 year-old woman, one year out of her surgery had been doing fine when her life was turned upside down with divorce and severe teenager behavior problems. Her weight skyrocketed. Once she got her depression under control and began refocusing on the rules of the pouch, added a little exercise, the weight came off quickly. If your patient begins weight gain due to depression, get him/her into counseling quickly. Encourage your patient to refocus on the pouch rules and try to add a little exercise every day. Reassure your patient that he/she did not ruin the pouch, that it is still there, waiting to be used to help with weight control. When they are ready the pouch can be used once again to lose weight without being hungry. EROSION OF THE USE OF PRINCIPLES: Some patients who are compliant, who are not depressed and have intact pouches, will begin to gain weight. These patients are struggling with their weight, have usually stopped connecting with their support groups, and have begun living their “new” life surrounded by those who have not had bariatric surgery. Everything around them encourages them to live life “normal” like their new peers: they begin taking little sips with their meals, and eating quick and easy-to-eat foods. The patient will not usually call their physician’s office because they KNOW what they are doing is wrong and KNOW that they just need to get back on track. Even if you offer “refresher courses” for your patients on a yearly basis, they may not attend because they KNOW what the course is going to say, they know the rules and how they are breaking them. You need to identify these patients and somehow get them back into your office or back to interacting with their support group again. Once these patients return to their support group, and keep in contact with their WLS peers, it makes it much easier to return to the rules of the pouch and get their weight under control once again. TRUE NON-COMPLIANCE: The most difficult problem is a patient who is truly non-compliant. This patient usually leaves your care, complains that there is no ‘connection’ between your staff and themselves and that they were not given the time and attention they needed. Most of the time, it is depression underlying the non-compliance that causes this attitude. A truly non-compliant patient will usually end up with revisions and/or reversal of the surgery due to weight gain or complications. This patient is usually quite resistant to counseling. There is not a whole lot that can be done for these patients as they will find a reason to be unhappy with their situation. It is easier to identify these patients BEFORE surgery than to help them afterwards, although I really haven’t figured out how to do that yet… Besides having a psychological exam done before surgery, there is no real way to find them before surgery and I usually tend toward the side of offering patients the surgery with education in hopes they can live a good and healthy life.

Congrats Amieru! I'll be thinking of you Tuesday morning. I had a really good experience overall in Parker and I hope that you do, too. Woofay, I am so sorry that you're feeling ill and hope that you're better soon. There's an awful flu going around here. I think it's possible you're not getting enough vitamins/healthy food, but it could also just be bad luck. You work at a school, right? I never stayed sicker than the year I was a parapro at a primary school. Kids are germy! That's when I started carrying around hand sanitizer. Cara, I read some real horror stories before my surgery too. When I had my phone consult with Dr. K, I asked him about complications and he mentioned five. I thought that they were all port revisions, tube punctures and/or tubes leaking. I don't remember him mentioning a removal, but you should feel free to ask him during your consult. There is the possibility of something going wrong with any surgery. But by going with an experienced surgeon, doing your research and resolving to follow his instructions to the letter, you are reducing your risk. That's all you can do.

I just had my revision yesterday......My port was detached and flipped.....DO NOT READ FURTHER IF YOU WANT A POSITIVE RESPONSE!! so it just started out bad bad to begin with.. instructions were to get there at 730... have blood work and then check in for surgery by 830 I was scheduled for the 10 oclock slot... I did all that was asked of me.. sat there for 3 hours and didnt go in for surgery till almost 11. ugh! Ok so they stuck me like 5 times looking to get an IV... I am terrible at getting IV's my veins just do not cooperate well... The best place is deep inside my arm between my wrist and elbow... hard to visually see the vein but if the person knows the anatomy then they can get it easy.... Last two surgeries that is where it has been....OK.. they wouldnt even look there... so I end up with a 22 guage needle in my finger...like a 2 year old would have... and they said once you are under we will get another IV in.... I say ok.. as long as I am asleep cause I cant take much more of the poking and searching..... Ok so fast foward to waking up... they didnt time it right and I woke up BEFORE the tube was out... so instantly the NEED to fight to breath happens and I cant because there is a tube in there.... thrashing and choking and cant breath... so they finally get the tube out and my throat is RIPPED up... sooo sore... raspy voice scratched throat... so not fun.... Had to go to short stay after surgery because my BP was 83/52 and it wasnt coming up... it was scary low... so they monitored that for a LONG time in recovery.... Ohhh and as I am waking up and trying to get my bearings after all that has been happening.. obviously weak from BP being so low... sore from surgery and everything else.. I realize I have an IV in my left shoulder... of all places... ugh! ok so back to short stay... she tries to give me some morphine for the pain...through the iv in my shoulder....it BURNS BURNS... she realizes that my shoulder is hard and swollen... the Fluid is collecting in my shoulder....OMG! what else can go wrong right?... Ok so finally I get home at 515pm....long ass day... Ohh and also... I was having my period on top of all of this... today is cycle day 3.... LOVELY!!! So the port is sutured back down... I am stitched up... and I have a small fill so I am on liquids till tomorrow... and then soft foods for 2 days...then I can eat normal after that... I am taking motrin and hydrocondone.... Pain is pretty intense..less then the actual lapband surgery ... but still intense...Hope to be off narcotics by tomorrow....Painful sleeping getting up and down...

Not finding anything specific unfortunately, at least nothing "new" or recent (or clearly outlined). Rebound rates aside, if you've got a slight reflux now, it will be amplified with the sleeve and reduced with the Bypass, based simply on what the surgery does. And in the off chance that you end up with a major problem... there is no going back after the sleeve, 90% of your stomach is rotting in medical waste somewhere (or been incinerated), with the bypass, everything (for the most part) is all still in there. The sleeve is ONLY a restrictive surgery, there isn't any reduction in caloric intake caused by the surgery itself outside of forcing you to reduce your intake, but then there are all the "slider" foods etc. I made the mistake of choosing the lapband back in 2011 because I was under-educated about the bypass, and well, I didn't want to make any permanent changes, which is ironic, because, I didn't get any permanent weight loss. So, second surgery to remove the band and revise to the bypass in March and I really couldn't be happier... I really do wish I went with the bypass from the get go. A personal (in real life) friend of mine had the sleeve, and he's getting it revised to the bypass because of the lack of progress. Just things to be aware of.

Getting a revision based on medical necessity (severe GERD) is a very important distinction and is helpful for everyone to be aware of. Secondly, everyone knows that revision surgeries are generally less effective when weight regain is involved, therefore the outcomes will be different. There is no expectation of weight loss. You might want to contemplate why this angers you.

I don't understand what you're trying to tell me here. Do you want to express that someone having revision because of GERD deserves support more than someone having revision because of regain? Because then we would actually really disagree.

Okay, I'm in for this challenge. Sadly, I had to go revise my ticker UP since the end of the Fall challenge. I've put off doing this as it SOOOO discourages me, but time to get clean and BACK to work... or working out as it were. My exercise was minimal over the holidays and omigosh WHAT a difference it makes. It's not like I don't already KNOW that. Since I always feel so much better when I'm working out regularly why the heck to I take breaks from it? Oh well, I'll try to stop beating myself up now. If I can go a week without feeling dissapointed in myself it would be a BIG NSV. An even 180 to start. By the end of this challend I want to in the 160's.

I am SO SORRY for your friend. I don't have any personal experience with Dr. N so you need to take what I say as being worth what your paying for it. However I have heard some other negative things both here on LBT and on Yahoo's KCBandster site. Everything from surgery induced infections to a couple years ago he was reported to be asking his patients to keep their fill needle so he could re-use it on their next visit. (Though that was stopped.) Another area doc I've heard bad things about is Dr. Opie out of Olathe. I have a friend who was banded out of state but was going to him for fills who just had to have a port revision because he punctured the tubing repeatedly while trying to giver her a fill. The two docs in town that I know well enough to reccommend are Dr. Malley and Dr. Hoehn. Dr. M is a proctor for Inamed/Allergan and has done over 1000 surgeries, he works out of New Hope Bariatrics. Dr. H has done well over 500 last I heard and the hospital he works out of (SMMC) was the first in the area to receive the Center of Excellence Rating. I was banded by H but now get my fills by M. I would trust both with my life as far as surgical skills go but if I were to start over I would have gone with M all the way instead, strictly based on staffing and program issues. Well that and the fact that I really like he has done the most in town and is the companies teacher for new docs in the region.

I like the Jay Robb, but you have to order on-line. I like the unflavored whey protein powder or the vanilla. For example, I use one package or one scoop of the vanilla, add 8 oz. of lactose-free milk (or regular if you can drink it,) 3 or 4 ice cubes, and 1/2 cup frozen peaches. It taste just like a peach milkshake! Of course, I have not been banded yet, so after surgery I will probably have to revise the recipe. With the vanilla you can add any frozen or fresh fruit you like. Wiith the chocolate I like a banana or strawberries. Okay, now I am hungry.

My biggest mistake was being too tight for months and vomiting everyday for 4-5 months finally had to get a complete unfill had nothing for a month gained 4 pounds my lesson learned respect your band hopefully after a barium swallow the band is intact by the grace of god after all that vomiting I thought it had slipped these were my options if it did go for another operation and readjust it to the correct position. revise to gastric bypass. or just leave it out all bad options meaning more operations luckily it was okay and I am on my way after months of no weight loss just vomiting eating and vomiting more what we do to ourselves its sickening.

Hi Coco, My issue with the aftercare isnt with the doctor or surgeon, its the cost of the hospital. Just becase the surgeon will do the fills ... and do the port revision surgery as part of the aftercare doesnt impact that the hospital has charges from the or, anesthesia, etc. So, thats where the money comes in. the Surgeons fees are cheap compared to that. allison

Wow...I logged back in to this platform as my journey continued and forgot this thread was here. I can’t believe I’ve been in this band nightmare for over 12 years!!! In 2007 I finally got the port removed. My doctor very nonchalantly said “it tested positive for MRSA infection”. I had NO idea the implications. He handed me a card for an Infectious Disease doctor and told me to go across the street to their office. Again, NO idea what was ahead. Suddenly I had a nightmare of a PICC line (took 2 excruciating days to insert) for Vancomycin and a wound vac system. I had both of these for weeks, my home was a virtual hospital. I even took that show to work a few times. Crazy. That was over 10 years ago. In those 10 years I had just the band. I’d never been able to get it removed because it wasn’t presenting obvious negative effects and my insurance wouldn’t cover it. After a decade I finally started the path to revision to a sleeve. I had the band removed on 10/26. It was very complicated. My outpatient procedure turned into 6 days in the hospital. The band had eroded into my stomach (common) but also had RAVAGED my small intestines. The new surgeon said he had never seen anything like it. He had to get the band out of several spots in the intestines and do a lot of repair work. While recovering, about 24 hrs after surgery, things went south. BP low, breathing shallow, heart rate up, fever...ugh. Many tests later and we determined that my chronic Diverticulitis had flared up and was causing the additional pain and infection. It was a very long 6 days, and the fevers kept coming. After being released and on a better coarse of oral antibiotics, things are finally better. It’s been 3 weeks and I am almost not in pain. It was a miracle I didn’t have a blockage, or major infections with that band. I now think my bowel perforations and infections may be related to the band. I had no idea and I guess the band was never visible in the CT scans. Anyway... I wanted to finish my 12 year saga. I’m almost second guessing the sleeve surgery. I feel like I am 4/4 with bad surgery issues...but the reality is that a lot of things (if not all) were caused by that awful band. I may have the surgery, but it will be after the New Year. That bums me out because it will very VERY expensive with out of pocket costs...but realistically I need more time to heal...and I am unable to miss a wedding on Dec 29th. Not sure anyone will read this...but that’s where I am. Xx

Hello, getting a revision from a band and am starting to have some questions. For a person who suffers from constipation which revision would be best the sleeve or bypass? Sent from my SM-N920V using the BariatricPal App

Success rate? 1)You call a 43% excess weight loss at 36 months with expert surgeons a success? You need to investigate- and further, 2)The largest or widest band available is NOT the Realize, its the LapBand APL 14cc vs 9cc. also their backing is wider, not the bladder. 3) If your doctor is a proctor - he is getting paid $5,000 per proctoring event and $10,000 per month for advertising from J&J - they offered my doc the same deal and she refused because it' an inferior prodcut. And trust me- she could use anything she wants. 4) If the Realize Band has such great success - please explain why 35 of 36 bands implanted in Canada had to be EXPLANTED. This was such a problem the Canadian FDA sent a letter to doctors asking them not to use it. You can try and make yourself feel better and rationalize it but your doctor did you an injustice by not giving you all the facts and information- don't be mad at me - be mad at him Swedish Adjustable Gastric Band: erosion and other reported incidents leading to explantation The Swedish Adjustable Gastric Band (SAGB) is an implantable, adjustable gastric band indicated for use in the treatment of morbid obesity in adults.1 It consists of a reinforced silicone gastric band fitted around the stomach and an injection port placed under the skin and connected to the band by tubing. The SAGB is designed to reduce food intake and can be inflated or deflated as needed after implantation to meet weight-loss requirements without the need for further surgery. The SAGB was originally licensed for sale in Canada in November 2002. A modified version of the device, the SAGB Quick Close (SAGB-QC), was added to the licence as part of a device licence amendment in August 2004.2 Although band erosion is listed among the possible adverse events in the device labelling for physicians,2 the device labelling for patients states that the overall rate of reoperation following placement of the SAGB is low and that extensive use of the SAGB has led to a method where failure is uncommon.3 By definition, band erosion is "a situation where a part of the band has eroded through the full-thickness gastric wall and migrated into the lumen."4 This represents a total failure of the gastric banding procedure.5 From Nov. 1, 2002, to June 15, 2007, Health Canada received 19 reports of incidents suspected of being associated with the SAGB and 17 with the SAGB-QC. Thirteen of the 36 reports described cases of band erosion necessitating removal of the band. Other reports described incidents such as band slippage, band leakage, abscess, dysphagia and regurgitation. In 35 of the 36 reports, band explantation was reported as an outcome. Although reported rates of band erosion vary across published studies, evidence in the medical literature suggests that the frequency of band erosion is approximately linear over time following surgery, with erosions still being diagnosed 5 or more years after implantation.4 5 Since band erosion is often asymptomatic or only mildly symptomatic initially and since the condition is best diagnosed by gastroscopy, which may not be included in the follow-up of asymptomatic patients, the true incidence of band erosion is underestimated in the literature and its diagnosis can be markedly delayed.4 5 Moreover, band erosion is associated with dense scarring and distortion of tissues, which can complicate revision procedures.5 The complication rates and outcomes associated with SAGB and reported in the literature are variable. Although the authors of some studies have concluded that use of the SAGB demonstrates acceptable levels of safety and effectiveness,6 7 others have reported high long-term complication and failure rates and poor long-term outcomes.4 5 The medical literature suggests that, until reliable selection criteria for patients at low risk for long-term complications are determined, alternative treatment options should be considered and gastric banding should be performed only in carefully selected and fully informed patients.5 Andrew Gaffen, BSc, DDS; Gina Coleman, MD; Health Canada References Swedish Adjustable Gastric Band [Canadian instructions for use]. Baar (SWI): Obtech Medical AG; 2000. Swedish Adjustable Gastric Band Quick Close [Canadian instructions for use]. Zug (SWI): Ethicon Endo-Surgery in cooperation with Obtech Medical AG; 2003. Swedish Adjustable Gastric Band Quick Close [Canadian patient manual]. Zug (SWI): Ethicon Endo-Surgery in cooperation with Obtech Medical AG; 2003. Gustavsson S, Westling A. Laparoscopic adjustable gastric banding: complications and side effects responsible for the poor long-term outcome. Semin Laparosc Surg 2002;9(2):115-24. [ PubMed] Suter M, Calmes JM, Paroz A, et al. A 10-year experience with laparoscopic gastric banding for morbid obesity: high long-term complication and failure rates. Obes Surg 2006;16(7):829-35. [ PubMed] Steffen R, Biertho L, Ricklin T, et al. Laparoscopic Swedish adjustable gastric banding: a five-year prospective study. Obes Surg 2003;13(3):404-11. [ PubMed] Zehetner J, Holzinger F, Tiraca H, et al. A 6-year experience with the Swedish adjustable gastric band. Prospective long-term audit of laparoscopic gastric banding. Surg Endosc 2005;19(1):21-8. [ PubMed]

Hi Ladies I had my surgery May 7th new to this site. My surgery is a revision to the Gastric bypass I had that done in 2006 started gaining the weight back in 2010 had a baby in 2011 and now I had the band done so I'm starting over again. With the bypass I loss 150 lbs I gained 80 of it back currently I'm down 10 lbs and counting good luck to everyone on this journey may we be a resource to one another.

I just had a revision to the sleeve in mid-August. I had my Lapband removed due to issues and knew I couldn't remove it without gaining weight again. It was much more involved than my out-patient Lapband surgery. I had my surgery around 12:00 noon, and I don't think I really woke up enough to even get up to go to the bathroom until 9:30 that night. I did not have a catheter or a drain. I had 5 incisions. My mouth was so dry I couldn't talk well. I did stay overnight. I had an IV and I did remember to ask for an abdominal binder to help when I tried to get up out of the bed. I used it for a while even when I got home. I actually tightened it too much and ended up with dots on my stomach for a bit, I guess from the elastic. It was quite an experience, but I am glad I did it. I haven't had reflux since then. I have been slow to lose weight, but I had already lost 100+pounds with my Lapband. I started with an app, logging everything I ate to help me keep track of protein and I think it actually helped me eat too much. I have scrapped it as of yesterday. We will see what happens. Good luck! I just had to keep telling myself the surgery part/liquid diet stuff was temporary.

Hey everyone. I'm soon to be revised from lapband to sleeve and I'm in PG county. Surgery being done by Dr. Salameh at Virginia Hospital Center. Would love to interact with some other weight loss surgery peeps for support in the DMV area. You can contact me here or directly poohressa@gmail.com

i think i found one vlog about a leak! she had to be revised to bypass after 2 or 3 failed attempts with the stent. she looked like she was standing on her last leg before kicking the bucket! she scared the daylights out of me!!! but of course when i told my mom or ppl that know about surgery, they all called me negative & told me it wont happen to me & i need to stop searching! yeah well, so much they knew because look at me now!!! i asked my nurse practioner & her answer was "u dont have to worry about a leak but if there were one, we would place a stent to cover the leak up until it heals & then everything will keep looking up". never ever ever ever ever did they go into detail about how its done, the pain, nothing! matter fact, i thought the stent was a pain free procedure UNTIL waking up in recovery from the procedure! then my gi dr didnt wanna give me pain meds!! he told me to give it a few hrs until i adjust! he didnt give me pain meds until i began crying hysterically!!! mind u, i was throwing up excessively! smh horrible horrible horrible!!!!!!!!!!! horrible!!!! just nightmare! smh! i think they need to go thru all the complications as if they were trying to sway ppl from surgery! in detail. thisway ppl grasp it! they emphasize all the good but no bad.

Thanks for the encouragement. I'm very excited to finally do something permanent. One of the selling points for me about getting the band in the first place was that it was reversible. What a fallacy that was. And not only that, who wants to reverse back to being fat? Was I going to wake up one day and say I'm tired of being thin, I miss being fat? Of course not. Now that I have this band I am miserable. Lost 2 jobs due to being out sick too long. All this for 35 pounds lost? Anyhow I am so grateful that I can have a revision to the sleeve when my band is taken out. Hopefully. I look forward to a permanent solution rather than the roller coaster ride called Lap Band.

I'm assuming you treat a revision like the first time? I would think Prilosec would be a great way to start! My kiddo is on prevacid now and her tummy would randomly hurt on and off during the day before they started her on it.

I have had a lap band for 10 years and yes, you get hungry with it but I will say that I never felt hunger pangs and bad as before. I am considering revision to sleeve and I know for sure that there is a head-hunger that is in no way related to my stomach. It occurs when I have any kind of anxiety such as a deadline at work or even when I an anticipating something good. I have no idea how to rid myself of that and it may be what others are experiencing.

My daughter is getting ready to have revision surgery from band to bypass and you have given her inspiration! The only thing she is afraid of is seeing a totally different person in the mirror.

I am almost 2 years out. I do not regret the decision to have weight loss surgery at all although if I had known I would end up needing a revision due to reflux I would have chosen bypass initially instead of sleeve but I had no way of predicting that. I'm down 172 pounds. From a 54 BMI to a 24 BMI. Russell stover makes delicious sugar free peanut butter cups. There are reese's and quest ones too. I made what I call peanut butter cup oatmeal for breakfast today which is oatmeal, pbfit powder for protein and Walden farms zero calorie chocolate syrup. I've had diet coke a few times but carbonation bothers me so I have to let it go completely flat and it isn't worth it. I don't miss it too much. My PCP wasn't super big on WLS but my insurance didn't require a referral from him and honestly when I went back for a regular visit about a year post OP he was happy to see that it had been successful for me to have surgery. I don't eat red meat often as I don't do as well with it since my galbladder was removed.

I'm March 16. Band to sleeve revision. I can't wait.