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I'm not a person to take risks and all I'm saying is, really; for me, going to Mexico is too risky. And expensive, out of pocket which is not an option for me right now. I'm half Hispanic/native American, I'm afraid they wouldn't let me leave. LOL And I'd get picked on for not speaking spanish. (no, i'm not illegal) But anyways, I was just stating an opinion. There's so many loops that we have to get thru for the insurance and surgeon and I don't mind them because I know I'll be ready. For example, Kaiser requires a full psych evaluation and group/individual sessions. I like that. Being able to vent to a psych who specializes in bariatric patients and has probably seen it all, is very comforting to me. CUZ I'm scared! I want to do it but I'm so scared about the surgical complications, not being able to stay away from my old eating habits, or gaining it back. There's a whole team I'm accountable to; dieticion, nutritionist, a nurse who calls me periodically to check in, the pshychologist and the surgeon. I was born with no thyroid so having this team, for me, is what I feel I need. I'm sure it's not everyone's preference. I was dead set against this surgery til a few months ago. Actually, I was set against the gastric bypass but then they told me about the sleeve and I jumped on board. I've watched so many youtube videos of people who have had the courage to do this and they inspired me. As for the money, I know they all make a mint, here and all over the world.

I had bypass 8/23. I've lost 75 pounds total(55 since surgery). The problem that I'm having is no matter what type of socks I wear, my leg swells at the top of the sock. I've tried ankle high , no show,crew, knee etc. They are not tight at the band but I still swell. Does this happen to anyone else? Sent from my iPhone using the BariatricPal App

Rny 1999 Bowel resection 2001 While 3 months pregnant 2008 plastics 2016 regain 10/25/18 revision Don't meddle in the affairs of dragons, for you are crunchy, and taste good with catchup!

I found a study about it. Apparently some people have had success with it. It's called laparoscopic re-sleeve gastrectomy. I didn't quickly find anyone doing it. Can you talk to your original surgeon? Most people get the bypass for regain and I do know someone doing well with that. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4073220/

I am so glad that you are feeling so much better and that your body is adjusting. I'm doing a lot better these days myself. I actually am beginning to experience some constipation. I began taking a liquid supplement by Bluebonnet called Calcium Magnesium Citrate Plus Vitamin D3. It helps me tremendously by keeping me regular and soft. I take it every evening along with my evening Vitamins and medications. I have progressed to solid foods and have found that some things don't agree with me as the once did. I used to love Peanut Butter. I have found that now it's too sweet and too oily. I can't stomach red meats either. Carbmaster has a new low carb smoothie that I tried today and it didn't sit well. I think the smoothie was too thick. I can still eat Carbmaster low carb yogurt with a scoop of added Protein. As of this past Monday 29AUG16 I started going back to the YMCA so I could swim in the early mornings. Well.. I started off doing Water aerobics for thirty minutes and swimming for ten minutes before I got tired. I have been going every day this week and have been increasing my endurance. I now do water aerobics for twenty minutes and swim for twenty minutes. When I get cleared by the surgeon I will begin to add some light weight lifting on Monday, Wednesday, and Friday so I wont loose all on my fat free muscle mass. I will see him in two more weeks. I must say that my weight loss has been considerably slower. My surgeon had prepared me by informing me that the weight loss would be slower than before. I just need to relax and let the process work no matter how long it takes. I'm not competing with anyone just my preconceived ideas of how this should work for me. I'm glad that you did read my response and know that I am here if you need me. Truthfully I need as much support as I can get especially since this is a revision and I am deathly afraid of failing!!. So please keep me posted of your progress as well. I really appreciate knowing that there is someone else on this board who has a similar background as I do. I don't feel so alone anymore. Thanks

Sleeve patients don't have a pouch. Bypass patients do. And that's correct, it's very hard to stretch a sleeve because the fundus is removed. A little Water won't stretch it. It really takes years of systematic overeating to the point of sickness to stretch a sleeve. I'm 2+ years out, and I still adhere to the no drinking rule pretty well. It's hard sometimes, but you do actually get used to it. I also drink right up until I eat, but never during (except maybe a sip if something is super dry) and always wait 15-30 minutes after. It's served me well, as I've been maintaining my weight within 4 pounds for a year now.

Went for a surgeon hunt started May 7- May 21, 2019 Research the bio, read there journals articles,made appointments with ONLY 3 surgeons in the Houston Area. Bed Side manner counts big time for me GI Doctor clearance and his GI physician assistance ( 2 letters) saying what type of surgery I need and the back up method if not approve for Gastro Bypass. May 7 & May 17 PCP Clearance (EKG, Physical and BLOOD WORK) May 14 Nut Clearance May 17 ( Mentally ready for Surgery) GI Nutritional Visit Clearance May 22 Pulm Clearance May 22 Pick My Surgeon and gave him ALL MY CLEARANCE paperwork May 23 Cigna paperwork sent in June 3 and APPROVE June 5 Ultrasound and Gastro Empty Test FINISH all ready - (I am waiting on a sleep study and Ph acid reflex 24 hour test!)

I'm just over 16 months out from bypass, and I still can't eat white meat chicken, or any dryer meats like pork chops, or steak, without hurling. The great thing is I still don't miss them. I can eat bacon though, but it can't be crisp.

Here's what I was told by my dr: "We take out the stretchy part of the stomach (why bypass pts gains back so much) and make it a 2oz pouch. Over a period of the first year, you CAN stretch it a little, but to no more than 8 oz. That's its stretch capabilities. It's why less sleevers gain back weight than bypass pts" I sure hope this is true...

Could you explain why? At the moment I am leaning towards gastric bypass because: 1) I don't want to be considering a revision surgery in a few years if I am not successful with the band. 2) The amount of maintenance a band requires (I live two and a half hours from my surgeon).

Hi, I don't know how much you weigh, but you are right about extra skin. You are young and have more elasticity even if you have some extra skin it won't be as much as some people 10-20 yrs older(usually). The other reason for doing the band vs bypass for me was that you have more control, it is reversable, you do not have as many problems with malabsorption. You will still need vitamins, but you won't have to worry about dumping(ok so I don't really know what that is but I don't think that it is plesant) All that being said, I am not banded yet but am looking forward to it. Good luck, research, research, research and then pick what will work best for you.

Had my first fill today! I found out I have a 10 cc band, with 3 cc's already in from surgery. He put 1 cc in. The doc was VERY happy with my weightloss. He says I'm on par so far with his bypass patients! And he didn't want to give me a fill - I said no way, I'm hungry! So he did. It wasn't that bad. He didn't give me any numbing medication or anything, and it hurt a bit, then a bit of pressure, but it wasn't intolerable or anything. Now that I know what it feels like, the next one won't be as bad.

Well, I guess it has been a few years since i wrote in this blog. So, I am having a revision from lap band to sleeve tomorrow. 9 Feb 15. I am excited but nervous. I would like to write every week. The exception will be this week. I will write after surgery and again over the week. See you on the Loser Bench!

Thank you all for your awesome feedback! I will continue to keep everyone updated. @@Dub as for you we will all be here for you too when your time comes for your surgery! I too had the gastric bypass surgery and we can share experiences too! If you have any questions please let me know. Your going to do great and I'm very excited for you too. This is one of the best groups I know of to come and share your story or concerns and questions, the people are awesome ????

lots of people revise to the sleeve. I'd caution you though, that if you have any reflux with the band (as many do) your best revision option will be bypass.

Hi there. I'm new. I've been researching, considering WLS for the past couple of months. I learned my insurance won't cover, so Mexica may be an option if I move forward. As I complete my health history for one clinic, I am wondering who is going to do surgery on a 60-year-old in poor health? Yet, I understand so many candidates receive surgery because of their health. - I've been hypothyroid for 20 years, which has progressed now to autoimmune thyroid. - I've had several surgeries over the years. Mainly: two cesareans, hysterectomy, hernia repair, gallbladder removal, pacemaker. I also have asthma, and neuropathy in feet due to degenerative disc disease. I've been referred to Mayo Clinic for what my doctor believes are autoimmune-related issues. Has anyone here been denied surgery due to health/age? I am considering WLS to help with health issues after I visit Mayo Clinic. I was told by one reputable clinic in Mexico I would not be a candidate for the sleeve; I'd need a gastric bypass if accepted. Getting this weight off (goal of about 85 lbs.) would help with arthritis and autoimmune, etc. Anyone have similar experience? I look at my application and realize I may just be beyond the scope of consideration. I'd appreciate some feedback. Thank you! I wish you all well in your journey!

Is there a military hospital that you can go to and get the sleeve if that is the surgery you really want. I refused RNY/bypass when I had to revise from the band and I listed the reasons below. I've also included the basic information about both surgeries. There are many reasons why I chose VSG instead of RNY, and my VSG was covered at a military hospital 100%. I would recommend checking out the obesityhelp.com website, look under surgical forums, check out the Revision forum so you can see how many people are looking to revise from RNY because of weight regain or complications, and then check out the failed weight loss surgery forum just so you can get an idea of people that are further out. Here are my reasons for getting VSG instead of RNY: The Vertical Sleeve Gastrectomy procedure (also called Sleeve Gastrectomy, Vertical Gastrectomy, Greater Curvature Gastrectomy, Parietal Gastrectomy, Gastric Reduction, Logitudinal Gastrectomy and even Vertical Gastroplasty) is performed by approximately 20 surgeons worldwide. This forum is titled “VSG forum” to include the two most common terms for the procedure (vertical and sleeve). The earliest forms of this procedure were conceived of by Dr. Jamieson in Australia (Long Vertical Gastroplasty, Obesity Surgery 1993)- and by Dr. Johnston in England in 1996 (Magenstrasse and Mill operation- Obesity Surgery 2003). Dr Gagner in New York, refined the operation to include gastrectomy(removal of stomach) and offered it to high risk patients in 2001. Several surgeons worldwide have adopted the procedure and have offered it to low BMI and low risk patients as an alternative to laparoscopic banding of the stomach. It generates weight loss by restricting the amount of food (and therefore calories) that can be eaten by removing 85% or more of the stomach without bypassing the intestines or causing any gastrointestinal malabsorption. It is a purely restrictive operation. It is currently indicated as an alternative to the Lap-Band® procedure for low weight individuals and as a safe option for higher weight individuals. Anatomy This procedure generates weight loss solely through gastric restriction (reduced stomach volume). The stomach is restricted by stapling and dividing it vertically and removing more than 85% of it. This part of the procedure is not reversible. The stomach that remains is shaped like a very slim banana and measures from 1-5 ounces (30-150cc), depending on the surgeon performing the procedure. The nerves to the stomach and the outlet valve (pylorus) remain intact with the idea of preserving the functions of the stomach while drastically reducing the volume. By comparison, in a Roux-en-Y gastric bypass, the stomach is divided, not removed, and the pylorus is excluded. The Roux-en-Y gastric bypass stomach can be reconnected (reversed) if necessary. Note that there is no intestinal bypass with this procedure, only stomach reduction. The lack of an intestinal bypass avoids potentially costly, long term complications such as marginal ulcers, vitamin deficiencies and intestinal obstructions. Comparison to prior Gastroplasties (stomach stapling of the 70-80s) The Vertical Gastrectomy is a significant improvement over prior gastroplasty procedures for a number of reasons: 1) Rather than creating a pouch with silastic rings or polypropylene mesh, the VG actually resects or removes the majority of the stomach. The portion of the stomach which is removed is responsible for secreting Ghrelin, which is a hormone that is responsible for appetite and hunger. By removing this portion of the stomach rather than leaving it in-place, the level of Ghrelin is reduced to near zero, actually causing loss of or a reduction in appetite (Obesity Surgery, 15, 1024-1029, 2005). Currently, it is not known if Ghrelin levels increase again after one to two years. Patients do report that some hunger and cravings do slowly return. An excellent study by Dr. Himpens in Belgium(Obesity Surgery 2006) demonstrated that the cravings in a VSG patient 3 years after surgery are much less than in LapBand patients and this probably accounts for the superior weight loss. 2) The removed section of the stomach is actually the portion that “stretches” the most. The long vertical tube shaped stomach that remains is the portion least likely to expand over time and it creates significant resistance to volumes of food. Remember, resistance is greatest the smaller the diameter and the longer the channel. Not only is appetite reduced, but very small amounts of food generate early and lasting satiety(fullness). 3) Finally, by not having silastic rings or mesh wrapped around the stomach, the problems which are associated with these items are eliminated (infection, obstruction, erosion, and the need for synthetic materials). An additional discussion based on choice of procedures is below. Alternative to a Roux-en-Y Gastric Bypass The Vertical Gastrectomy is a reasonable alternative to a Roux en Y Gastric Bypass for a number of reasons Because there is no intestinal bypass, the risk of malabsorptive complications such as vitamin deficiency and Protein deficiency is minimal. There is no risk of marginal ulcer which occurs in over 2% of Roux en Y Gastric Bypass patients. The pylorus is preserved so dumping syndrome does not occur or is minimal. There is no intestinal obstruction since there is no intestinal bypass. It is relatively easy to modify to an alternative procedure should weight loss be inadequate or weight regain occur. The limited two year and 6 year weight loss data available to date is superior to current Banding and comparable to Gastric Bypass weight loss data(see Lee, Jossart, Cirangle Surgical Endoscopy 2007). First stage of a Duodenal Switch In 2001, Dr. Gagner performed the VSG laparoscopically in a group of very high BMI patients to try to reduce the overall risk of weight loss surgery. This was considered the ‘first stage’ of the Duodenal Switch procedure. Once a patient’s BMI goes above 60kg/m2, it is increasingly difficult to safely perform a Roux-en-Y gastric bypass or a Duodenal Switch using the laparoscopic approach. Morbidly obese patients who undergo the laparoscopic approach do better overall in their recovery, while minimizing pain and wound complications, when compared to patients who undergo large, open incisions for surgery (Annals of Surgery, 234 (3): pp 279-291, 2001). In addition, the Roux-en-Y gastric bypass tends to yield inadequate weight loss for patients with a BMI greater than 55kg/m2 (Annals of Surgery, 231(4): pp 524-528. The Duodenal Switch is very effective for high BMI patients but unfortunately it can also be quite risky and may be safer if done open in these patients. The solution was to ‘stage’ the procedure for the high BMI patients. The VSG is a reasonable solution to this problem. It can usually be done laparoscopically even in patients weighing over 500 pounds. The stomach restriction that occurs allows these patients to lose more than 100 pounds. This dramatic weight loss allows significant improvement in health and resolution of associated medical problems such as diabetes and sleep apnea, and therefore effectively “downstages” a patient to a lower risk group. Once the patients BMI is lower (35-40) they can return to the operating room for the “second stage” of the procedure, which can either be the Duodenal Switch, Roux–en-Y gastric bypass or even a Lap-Band®. Current, but limited, data for this ‘two stage’ approach indicate adequate weight loss and fewer complications. Vertical Gastrectomy as an only stage procedure for Low BMI patients(alternative to Lap-Band®and Gastric Bypass) The Vertical Gastrectomy has proven to be quite safe and quite effective for individuals with a BMI in lower ranges. The following points are based on review of existing reports: Dr. Johnston in England, 10% of his patients did fail to achieve a BMI below 35 at 5 years and these tended to be the heavier individuals. The same ones we would expect to go through a second stage as noted above. The lower BMI patients had good weight loss (Obesity Surgery 2003). In San Francisco, Dr Lee, Jossart and Cirangle initiated this procedure for high risk and high BMI patients in 2002. The results have been very impressive. In more than 700 patients, there were no deaths, no conversions to open and a leak rate of less than 1%. The two year weight loss results are similar to the Roux en Y Gastric Bypass and the Duodenal Switch (81-86% Excess Weight Loss). Results comparing the first 216 patients are published in Surgical Endoscopy.. Earlier results were also presented at the American College of Surgeons National Meeting at a Plenary Session in October 2004 and can be found here: www.facs.org/education/gs2004/gs33lee.pdf. Dr Himpens and colleagues in Brussels have published 3 year results comparing 40 Lap-Band® patients to 40 Laparoscopic VSG patients. The VSG patients had a superior excess weight loss of 57% compared to 41% for the Lap-Band® group (Obesity Surgery, 16, 1450-1456, 2006). Low BMI individuals who should consider this procedure include: Those who are concerned about the potential long term side effects of an intestinal bypass such as intestinal obstruction, ulcers, anemia, osteoporosis, protein deficiency and vitamin deficiency. Those who are considering a Lap-Band® but are concerned about a foreign body or worried about frequent adjustments or finding a band adjustment physician. Those who have other medical problems that prevent them from having weight loss surgery such as anemia, Crohn’s disease, extensive prior surgery, severe asthma requiring frequent steroid use, and other complex medical conditions. People who need to take anti-inflammatory medications may also want to consider the Vertical Gastrectomy. Unlike the gastric bypass where these medications are associated with a very high incidence of ulcer, the VSG does not seem to have the same issues. Also, Lap-Band ® patients are at higher risks for complications from NSAID use. All surgical weight loss procedures have certain risks, complications and benefits. The ultimate result from weight loss surgery is dependent on the patients risk, how much education they receive from their surgeon, commitment to diet, establishing an exercise routine and the surgeons experience. As Dr. Jamieson summarized in 1993, “Given good motivation, a good operation technique and good education, patients can achieve weight loss comparable to that from more invasive procedures.” Next: Advantages and Disadvantages of Vertical Sleeve Gastrectomy >> This information has been provided courtesy of Laparoscopic Associates of San Francisco (LAPSF). Please visit the Laparoscopic Associates of San Francisco. Advantages and Disadvantages of Vertical Sleeve Gastrectomy Vertical Sleeve Gastrectomy Advantages Reduces stomach capacity but tends to allow the stomach to function normally so most food items can be consumed, albeit in small amounts. Eliminates the portion of the stomach that produces the hormones that stimulates hunger (Ghrelin). Dumping syndrome is avoided or minimized because the pylorus is preserved. Minimizes the chance of an ulcer occurring. By avoiding the intestinal bypass, almost eliminates the chance of intestinal obstruction (blockage), marginal ulcers, anemia, osteoporosis, protein deficiency and vitamin deficiency. Very effective as a first stage procedure for high BMI patients (BMI > 55 kg/m2). Limited results appear promising as a single stage procedure for low BMI patients (BMI 30-50 kg/m2). Appealing option for people who are concerned about the complications of intestinal bypass procedures or who have existing anemia, Crohn’s disease and numerous other conditions that make them too high risk for intestinal bypass procedures. Appealing option for people who are concerned about the foreign body aspect of Banding procedures. Can be done laparoscopically in patients weighing over 500 pounds, thereby providing all the advantages of minimally invasive surgery: fewer wound and lung problems, less pain, and faster recovery. Vertical Sleeve Gastrectomy Disadvantages Potential for inadequate weight loss or weight regain. While this is true for all procedures, it is theoretically more possible with procedures that do not have an intestinal bypass. Higher BMI patients will most likely need to have a second stage procedure later to help lose the rest of the weight. Remember, two stages may ultimately be safer and more effective than one operation for high BMI patients. This is an active point of discussion for bariatric surgeons. Soft calories such as ice cream, milk shakes, etc can be absorbed and may slow weight loss. This procedure does involve stomach stapling and therefore leaks and other complications related to stapling may occur. Because the stomach is removed, it is not reversible. It can be converted to almost any other weight loss procedure. Considered investigational by some surgeons and insurance companies. Next: >> Frequently Asked Questions About Vertical Sleeve Gastrectomy This information has been provided courtesy of Laparoscopic Associates of San Francisco (LAPSF). Please visit the Laparoscopic Associates of San Francisco. Bypass information

She did sum it up perfectly! I did contact my insurance company and the bypass and lapband are their two options. I just don't understand it. I've seen others have the same insurance as I do, and have the sleeve. Ugh. I just don't know what to do, but more research. Thanks for your input. Much appreciated to both you and Tiff. JJ

Jennifer, You are a young thirty, I am thirty one and I have a friend who had gastric bypass. She went with me to my intial consultation and she asked my surgeon to explain his choice. And he said, I was young, lap band is reversible, less evasive, blah blah! The main thing that stuck with me is.... I am young and I can do this! Bypass is easier because you don't have to work that hard at losing weight. But as someone else mentioned, why cut your stomach off? Also, when something comes so easy.....maybe that's why the weight comes back with bypass. Because you didn't work at it! I have not been banded but I believe the lap band is a better choice and you have to work with the band and be dedicated to a change in your life. If you work with the band and have a regular excercise routine. It will work in your benefit and perform just as good as the bypass. Things that come fast are not always the best.... NO matter what anyone says...You have to look at what's best for you. Explore your history and really dig and find out how you gained the weight(i.e. overeating, choices in food, or whatever your reason), and think about how you lose weight, and how you have to work at losing weight. And I think you will find your answer there.... Just my 2 cents

Hi Guys I found this site and think it will answer your question plus other information. The second point answers the life of the band question. LAP-BAND® System Surgery Frequently Asked Questions </SPAN> LAP-BAND® System FAQs | Gastric Bypass Surgery FAQs | Bariatric Surgery FAQs 1. What are the advantages of having LAP-BAND® Adjustable Gastric Band Surgery instead of gastric bypass surgery? See the LAP-BAND® Adjustable Gastric Band Surgery Information page 2. Should I have the LAP-BAND® Adjustable Gastric Band taken out once I lose the weight? No, the band is designed to stay in for a lifetime. Studies show that most patients will regain their weight if they have the band taken out. 3. Do I have to have adjustments for the rest of my life? How many adjustments will I need? Patients may need a little adjustment to the band volume every couple of years after the incremental adjustments required at the beginning. The average patient will come in for adjustments 6 to 8 times in the first year after surgery and may come in for an adjustment once or twice the second year. Patients may not need an adjustment at all in the third year. 4. Why don't you just "crank it up" and make the band tight all at once during surgery? The body needs to adjust to the new band. There is a little bit of swelling immediately after surgery and tightening the band too early or too fast has been shown in the research to result in more complications (including having to have the band taken out). 5. Is there such a thing as having the band tightened too much? Yes, the band can be over-adjusted. When the band is too tight, patients cannot eat solid foods without regurgitating the food or feeling very uncomfortable for many hours. When the band is too tight, patients tend to gain weight because they are resorting to the liquid and/or softer foods that travel through the band easily. These foods tend to be higher in fat and higher in sugar. When patients start this dysfunctional eating pattern, they are taking in more calories than if the band was looser. A band that is too tight will also cause heartburn and coughing in some patients. 6. What happens if 10 years from now I start to gain weight? What do I do? We see you annually in the office for a check-up, however if you are gaining weight, it is time to come in so that we can assess the problem. It could mean that you need a little adjustment in your band volume to provide a little more restriction. There may be a problem related to the types of food you are eating or there may have been a life crisis and emotional eating or depression may be taking hold. 7. What is the LAP-BAND® Adjustable Gastric Band made out of? The LAP-BAND® Adjustable Gastric Band is made out of silicone and titanium. 8. Is it possible for a person to reject the band? Yes, it is possible to have a reaction to any foreign body. Studies on the LAP-BAND® Adjustable Gastric Band have shown that it is extremely rare. 9. Do adjustments hurt? There are fewer nerve endings in the skin of the abdomen and patients say that the adjustments are nearly painless. Patients have said that the needle stick hurts less than a shot and less than the needle stick for blood studies. 10. Are adjustments made in the surgeon's office? Yes, adjustments are made in the surgeon's office. On a rare occasion, the port is difficult to feel and a patient may have to go to the radiology department to have the port accessed under fluoroscopy. 10. How long has the LAP-BAND® Adjustable Gastric Band been in existence? LAP-BAND® Adjustable Gastric Band was first placed in a patient in Belgium in 1994. The FDA approved the LAP-BAND® Adjustable Gastric Band for use in the U. S. in June of 2001. 12. How much weight loss can I expect with LAP-BAND® Adjustable Gastric Banding Surgery? For the first 1-2 years you should expect 1-2 pounds of weight loss per week. In the long term, you can expect to have 50-70% of your excess weight stay off. 13. If after surgery, and despite following all the rules, I am at a plateau of weight loss, what should I do? Plateaus are a normal part of the weight loss process. In the first year or two after surgery, weight loss plateau usually means that you need to come in and have a little bit of Fluid put in the band to increase restriction. Occasionally, plateaus are caused by the Band being too tight. If the Band is too tight, weight loss will resume after a little fluid is taken out of the Band. If the above causes are ruled out, we will have you keep a food and exercise diary. The diary will include the times and quantities of foods eaten, drinks taken, Protein grams consumed, and an exercise log. We may have you consult with the dietician as well. 14. What should I do if I "can't cope" after surgery? Weight loss surgery causes a lot of changes in a patient's life including dietary changes and development of a new lifestyle. With any change in our lives, there is a feeling of loss of previous life patterns. Patients may have feelings of sadness, anger and frustration when going through so many changes at once. We remind patients to be patient with themselves! We advise patients that if they experience persistent sadness for more than 14 consecutive days, along with loss of interest in things they were previously interested in, they should contact the Bariatric Center or their primary care physician. These are signs of depression. 15. What should I do if I cannot exercise very much due to back pain? We know from experience and scientific research that you will decrease post-op complications and increase your chances of weight loss through following the pouch rules and nutrition handbook AND being more active. We encourage you to find resources in your community to help you develop a program of movement and activity. For example, many of our patients with joint problems enroll in Water exercise programs at a therapy pool. Others find that recreation programs have recumbent exercise bicycles that allow you to sit while pedaling a bicycle. 16. I'm worried that after surgery, my emotional eating will return. Want can I do? Here are several suggestions we give our patients: Talk about your feelings with your support persons. Perhaps the stress in your life is high and you are returning to old habits of coping. Schedule an appointment with the behavioral nurse or other specialists to explore alternatives to dealing with emotions in ways other than eating. Call the bariatric center and ask for assistance. Attend support group meetings to hear how other patients are solving that problem. 17. What is the purpose of support groups? There are many benefits to attending support groups; here a just a few of them: To hear from others who have similar problems to your own To Celebrate positive changes in each patient's life since the surgery To learn new information about bariatric lifestyles To brainstorm solutions to problems To provide motivation to follow the rules that will work for individuals for a lifetime To meet people who have had successful results of the surgery and are willing to help others To talk with a group of people who understand your journey like no one else does! 18. How much pain will I be in after LAP-BAND® Adjustable Gastric Banding Surgery? Most patients experience mild to moderate pain. A common analogy used by patients post-op is that it "feels as if they did 200 hundred sit-ups in a row and their abdominal muscles are sore". More pain is commonly felt over the port site incision. Your pain will be well controlled so you will be able get up out of bed to walk and move around after surgery. 19. When will I be allowed to drink after surgery? You will most likely be able to drink Clear liquids on the day of surgery or the day after your surgery. 20. If I qualify for same day discharge, how long will I be in the hospital? Starting from the time you reach the surgical floor to recovery, it has been on average 6-8 hours. Times differ from patient to patient. 21. What are the expectations of patients in the hospital after surgery? Get up out of bed Walk in hallways as much as tolerated Sit in chair as much as tolerated Use your incentive spirometer (plastic breathing device) 10 times per hour while you are awake Concentrate on fluid intake Work on achieving good pain control with your nurse prior to discharge 22. What is the age range for being eligible for LAP-BAND® Adjustable Gastric Banding Surgery? Age range is 18 to 75 years of age but depends on the individual surgeon’s preference. 23. How many days off work will I need to take for the surgery? Depending on the type of surgery and the surgeon’s preferences, most patients take 3-5 days off from work for LAP-BAND® Adjustable Gastric Banding surgery. It varies from patient to patient.

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

Doctors in the South, Florida area are starting not to do the lap band procedures anymore. Their saying, its having too many erosions and revisions. Ugh!! Anyhow, I notice in other states within the US they no longer doing lapbands. Anyone else is knows of this too?

I have a good lap band surgeon with good follow up. The first 2 years are included with the surgery he says that he does less lap bands now. I've been ready about the complications. But I'm also concerned about absorbing calcium. My mom had a gastric bypass many years ago and can't absorb calcium and has osteoporosis. Have a small area of my spine with osteopenia. My sister had the sleeve this year and now needs surgery for scar tissue. I was all for the band but these stories are scaring me.

Looking for people who are still sick after they eat. Have had their Roux de Y Gastric Bypass surgery a few years back. Anyone suffering malnutrition? Having hard time with vitamins? Had a Dr that says he wishes you hadn’t had the surgery? I need to relate to another person who may be like me right now. Ty. No hurry in answers. I’m busy working but will check in. Ty ty

Welcome! I'm having my revision on the 21st!