SteveT74

Separ, I am trying to make the same decision myself and have been researching the heck of this subject. It doesn't help that the medical community is split on this subject--just like many of us. There are some facts about both procedures that are not in dispute. First, if you have Type 2 Diabetes, there are multiple studies that show that bypass has substantially greater likelihood of resolving diabetes when compared to other surgical options. Researchers don't know exactly what mechanism is triggered by bypass that makes so much more effective--but the result is clear (particularly for people with mild to moderate T2DM who have had the disease for 8 years or less). Gastric Sleeve is also beneficial for those with T2DM, but not to the same degree. Second, if you have acid reflux (all the time, not just after a crazy night of Mexican or Indian food), sleeve is probably not the way to go. It can make reflux worse and it can cause reflux in people that didn't have it before the surgery. The reflux can be control with proton pump inhibitors (pepcid ac etc.), but it's not great to be on those long term. In the alternative, bypass is used as a treatment to reduce reflux for people that suffer from it. Third, gastric sleeve is a less invasive procedure (although it is still major surgery), but the complication rate between the two procedures are pretty comparable. There are some small statistical differences that favor the sleeve, but those numbers don't really have much real world significance. Some of the historical data for bypass is skewed because the surgery was done as an open procedure in many cases before 2011. It's almost exclusively done laparoscopically today--which reduced the complication rate so it's pretty much the same as the sleeve. Fourth, the prep and recovery from both procedures is the same, so that shouldn't be a factor in your decision. Fifth, many people that have bypass experience dumping syndrome, which makes it difficult to process simple carbohydrates and greasy/fatty fried foods. If you have a carb addiction, this will stop you from eating those carbs--and it will punish you. There's a funny story about Al Roker (who had gastric bypass) having explosive diarrhea while he was visiting the White House years ago (worth a google). You can have some food intolerance after sleeve, but it's not the same by any means. Sixth, gastric bypass has a malabsorption component, which requires more supplementation than is required for the sleeve. There are some long term studies which show that after several years, your body adjusts and the malabsorption component is less of an issue (and less of a benefit). The jury is still out on this. Seventh, there is a dearth of long term studies on sleeve, so we don't know how effective it will be 10 years post op and what long term issues might arise. Bypass has been around for a lot longer, so we do know that it is generally very effective for the long term. We do know that sleeve and bypass have reasonably comparable weight loss results at the 3 and 5 year mark, although people tend to lose about 5-10% more with the bypass and they lose it faster (which may or may not be a good thing). Eight, gastric sleeve can be revised and converted to a bypass or a duodenal switch if you fail to lose sufficient weight or have difficulty controlling diabetes or reflux. The benefits of revision are limited when compared to your first surgery (at least as far as weight loss is concerned). The options for revising gastric bypass are more limited. That said, many bariatric surgeons believe that you should go with what they consider the more effective and proven surgery out of the box and that shouldn't go into your primary surgery thinking that if doesn't work out you can just switch it up later on. Moreover, there is a higher complication rate with revisions, revisions are less effective than primary procedures and some insurance carriers have more challenging criteria for qualifying for revisions than primary surgeries. Ninth, for people that: (i) extremely high BMI's (over 70); (ii) are older (over 65); (iii) have pulmonary or heart issues; and (iv) have had significant abdominal surgery in the past, gastric sleeve may be preferable. It takes less time to perform; therefore, you are under anesthesia for shorter period of time. It also doesn't require any rearrangement of the intestines/digestive track. Tenth, if you need to take time released medicine or NSAID's for pain management, gastric bypass may not be the way to go. You can develop ulcers in the unused portion of your stomach and they are not easy to treat. This is definitely a disadvantage of the bypass IMO. I am sure there are some other factors to consider, but these are some of the big ones that strike me as important. I have to make the same decision as you. I am a 44 year old man, 5'9'' and I weighed ~260 at my highest weight (around 245 now). I have mild-moderate T2DM, but a relatively low BMI (just over 35). I am leaning towards bypass because I really want this procedure to resolve my T2DM and I want what I hope will be the most effective. I will have to change some of my medications in the future if I go this route. The surgeon that I am currently working with is a big advocate for the sleeve. I have an appointment to meet with another surgeon in a couple of weeks for a second opinion--so I have definitely not made up my mind yet (and I was also told that I can change my mind last minute--although I assume that means a few days before the surgery date). Anyway, good luck with your choice and ask as many questions as you want!

If you're taking metformin, I assume you have type 2 diabetes. I do as well and in May my doc put me on Victoza, which causes weight loss. I lost 15 pounds just from taking that medication (brought down my A1C too)--believe it wasn't from dieting. Just a thought....

On June 8, 2018, EmblemHealth GHI also changed their criteria by "remov[ing] pre-surgical dieting prerequesite and statement that member must not have a life threatening condition". Of course, my surgical center didn't know this until I brought it to their attention yesterday (just as I am completing my six months of pre-surgical dieting and monitoring (I started the process in March). Of course, this is annoying for those of us that were stuck in the middle, but it's a good thing overall--since you're not going to rejected from coverage because of any weight gain or lose (or insufficient loss) etc. These changes are consistent with American Associate of Metabolic and Bariatric Surgery recommencations and position paper from 2016 and all the latest studies which show that these approval requirements are not supported by any medical evidence. To the contrary, the evidence shows these requirements are harmful. I expect more insurance carriers have changed their policies are will soon be changing their policies to fall in line.

This shouldn't be a binary choice between your health and that of your daughter. I see you live in Illinois and have private insurance, which assume is through your employer (Hospitals usually offer good health plans that cover bariatric surgery). With a BMI of 46 and assuming you are healthy enough for surgery, you should be able to qualify for coverage under your insurance policy. If you're daughter is 21 and a college student, she should also still be covered under your insurance plan (assuming you have a family plan). If you don't have a family plan, you should upgrade your policy to family so your daughter is covered. If that's the case, you should both be able to have the surgery (assuming your daughter also meets the criteria). If you have health insurance provided by your employer doesn't cover bariatric surgery (some policies don't provide this coverage), you may want to change policies. Your employer may offer a better policy (for a higher monthly premium) that provides coverage for bariatric surgery and it would probably be more cost effective to pay a higher premium for a better policy with bariatric coverage as a family plan (which would be paid for using pre-tax dollars deducted from your pay check) than going to the private market for a better policy or paying for the procedure out of pocket (for one or both of you). If going through your employer's health insurance options doesn't get you and your daughter the coverage you need, you can purchase an individual family plan through the open market or, better yet, you may (depending on your state law) purchase a group policy (which will have a much lower premium). I know in New York, all you need to qualify to purchase a group policy is to own a company that has three members (they don't have to be paid). So if you form a corporation (costs very little to do), and you make yourself president, your daughter secretary or your husband or other relative treasurer, you quality to purchase a small group policy for your business and employees. You only have to offer that policy to all your "employees" even if you're the only one that buys the family policy through this group plan (at least in NY--but I wouldn't be surprised if Illinois has a similar provision). You can pick an excellent plan with bariatric coverage for your family, which would be much cheaper than going out and buying an individual plan through open market. You and your daughter cannot be denied coverage for pre-existing conditions, so that is not a concern. Even if this type of plan would cost $20,000 for the year, it would be a hell of a lot cheaper than paying for even one bypass or sleave out of pocket. To set this up, you would need to talk to smart and experienced insurance broker (broker won't cost you anything) and maybe an attorney (setting up a corporation, even through lawyer, should only cost $500 to $1000 dollars). The option to go to one of the lower cost centers in Neveda or Mexico (Tijuana) is not terrible choice either. The reputation for the facility in Tijuana is actually really good, but it would be better to have it done by a surgeon that's close enough to you that you can go him or her for follow up and they will be accessible if an issue arises. If none of these options works (for whatever reason) and you are left with a binary choice between you and your daughter, at your age, I would suggest you have the surgery first. Your risk factors are likely higher and your state of disease is likely more advanced due to age. Your opportunity to benefit from this surgery and reduce the harm caused by obesity and any morbidities is higher now than it will be in 5 years. At 21, your daughter will have more time to have and benefit from this surgery during her life. Obesity is terrible for anyone, but at 21 her body can handle the stress from obesity better than yours over the next five years. Look at it this way, it's like the safety instructions they give you on the plan. If the air masks drops from the ceiling due to sudden decompression, you put the mask on yourself first than on your child. Same rule applies here IMHO. Again, this should not have to be a binary choice. If you are creative, you should both be able to get this surgery. If there are any specifics about your situation that is preventing you and your daughter from both getting the surgery through insurance, please let us know and that might change the guidance we give.

@TropicalBeachDoll I can't believe they felt an "intervention" was necessary to stop you from doing something that you really benefit fit you and allow to live a longer, healthier life with better quality of living. You must have had the patience of a saint to be able to sit there for 3 hours and listen to them (well intended or not). For the most part, I am keeping my decision to myself (aside from discussing it with my wife, parents and the HR department at my job--since I am going to need an accommodation so I can have the time off for the surgery and recovery, tests etc.) As far as family reactions go, my dad and wife had the same type of negative reaction at first that your family is having (mom is 100% behind my decision). My dad asked me a few questions about the procedures, but never gave me his opinion on whether I should go forward with this decision and, according to mom he is really uncomfortable with the idea of me having this surgery and won't discuss it with me (probably because my mother would kill him if he tried to dissuade me). My wife is really worried about the procedure (understandable) and whether it would be worth it in the end (it will be), but she read the information I gave her and is on board (sort of, but not really). In the end, it's my body, my choice. While I value my wife and parents' opinions, this is my call to make and I made it. I know that having this surgery is going to make a huge positive difference on my life and health. I am not going to be one of those people that gives in to fear and/or family pressure, only to find myself in a terrible state of health 10 years from now wondering how my life would have been different had I had the surgery.

Congrats to you and your husband! Wow, losing 6 stone and actually keeping it off with surgery alone is really a major accomplishment!!! He should be proud of himself. I have lost lots of weight in the past, but then I hit a wall and can't lose any more--get frustrated--and then after a while start to slip up. Once that happens, it seems like 2 or 3 months later all the weight is back and then some. I can't do this yo yo dieting any more---it's literally killing me. I really feel for you guys suffering through NHS process in the UK. Despite all of the current scientific data, the UK (and in other countries with socialized medical systems) huge demand for these procedures and not enough doctors available to perform them (nor the hospital capacity). So it all gets rationed out and they make the process hard that only a handful of people make it to the surgeon's table. It takes the average person that qualifies for bariatric surgery in the UK an average of over 2.7 years to get from the initial referral from the patient's GP to the surgery theater (as of 2016) and that's assuming you get through those arbitrary barriers to treatment once you get the referral to secondary care. Just to get your GP to give you a referral for secondary care requires you to jump through tons of hoops so you can document your weight loss attempts and lifestyle changes for the referral. In reality, you're talking a 5+ year process for most people in the UK, depending on whether you have a GP that is willing to spend the 10 minutes to write you a referral and not shame you for being fat (Imagine if they did that to someone that suffered from anorexia or some other eating disorder, much less someone with cancer or drug addiction). One study was completed in 2016 that tracked 22 people through the NHS process for bariatric starting in 2012 (all of whom qualified for surgery based on NICE and their regional guidelines). Of the 22 people that started the process, 12 ended up getting referred back to their GP (to start over) and only 6 received their surgery by the time the study was completed in 2016. Here's the study: https://academic.oup.com/jpubhealth/article/39/1/163/3065701 You really need to fight to get this life saving and life changing surgery. Fortunately, in May 2018, NICE updated its guidelines so that people that are recently diagnosed with type 2 diabetes and have a BMI over 35 should be fast tracked to surgery (which makes sense since the surgery could stop the progress of the disease before it causes any real harm). Unfortunately, getting expedited processing still could take a couple years before a patient can get on the list for surgery.

Hi Guy, This is my first post to the forum, but I have been doing a ton of research lately and I am trying to decide whether surgery is right for me and which procedure to go with. I am a 44 year, 5'10" and at my highest weight I was 258. I was always a thin guy up until my late 20's (when I was generally around 185). In my late 20's, I somehow managed to get up 210, then went on diet and started working out and got back down to 185 in a couple of months. Then I got married and got up to 220, then back down to 200, then back up to 241, then down to 215, then back up to 256, then down to 217. Now, I am 44 was back up to 261 of June this year. The pattern is pretty clear and continuing going up and down the scale isn't doing me any favors. I was sort of on the fence about surgery, but last month I was diagnosed with Type 2 diabetes and that freaked the crap out of me. I always knew I was at risk cause I get the fat all in my tummy, but it's one thing to be at risk and another to actually have the disease. I also have high cholesterol, high triglicerides and sleep apnea. At this point, I am really concerned about my health. I am married and I have two young daughters, 2 and 7, and I would like to live to see grand children someday (and live with good health--not with crappy quality of life). My cardiologist referred me to a bariatric surgeon in March, so I have been through the initial seminar, consultation, nutritional counseling and monthly weigh-ins. At that time, I was leaning towards VGS, but that was before I was diagnosed with diabetes. Now, I am thinking maybe RNY is the better option? I would like to be able to consider mini-gastric bypass, but it doesn't seem like any doctors in the NY area perform this procedure (I don't think many in the US do it actually). I am kind of scared about doing this, but more scared about not doing it. Is there any reason why I should go with VGS over RNY??? Thanks in advance for the advice!!!

In socialized medical system, it's a lot harder to fight and appeal denials of procedures. I don't know how the system works in Argentina, but some nationalized health systems (UK for instance) have loosened some of these requirements based on more recent studies. The problem you guys have is that some of these arbitrary requirements are used as a way to reduce the number of potential patients and ration out care to the patients that the state managers determine would benefit most. For all the complaints we have in the US with the cost of medical coverage and issues dealing with insurance companies, we do not have any rationing of care, long waiting lists to get an appointment for the operation and you can pick your doctor (and there are a lot of them to choose). Every time I hear people on the far left in the US call for "medicare for all" or some other nationalized health care system like in the UK, Canada etc., I think of the dark side of those systems and I'll take what we have here any day before we become a nation of rationed health care.

I have EmblemHealth GHI and they had a six month requirement of medically supervised nutritional monitoring and counseling, but no weight loss benchmark. I was 4 months in when, in June 2018, they revised the criteria to eliminate the requirement. The major bariatric organizations and institute (See, e.g., American Society of Metabolic and Bariatric Surgery's Updated Position Paper on Preoperative Supervised Weight Loss Requirements (March 2016) have all come out with position papers saying that these types of requirements serve no medical benefit, are not supported by any scientific evidence and only delay necessary treatment--which can harm patients (particularly those with co-morbidities like Type 2 diabetes). If you (or anyone else) is denied coverage because you have failed to meet this arbitrary and ridiculous requirement, you have a very good basis for challenging the denial. This requirement only serves as a barrier to necessary treatment for patients who stand to benefit from it. The new position advocated by most major institutes and associations is that surgery should be determined based on the BMI you present with at your initial consultation with the bariatric surgeon. EmblemHealth is hardly a trailblazer when it comes to loosening their approval standards and criteria, so if they did away with this requirement you can best most other companies will be revising their policies in the near future. I would definitely fight hard if any body's carrier denied coverage based on your purported failure to meet this arbitrary and pointless requirement. Although this may be slightly off topic, many insurance companies have other similar absurdities in their requirements. For example, many require that you do not have an active eating disorder. With few exceptions, every person who has a BMI over 35 (and definitely if you're over 40) likely has an active eating disorder (binge eating, carb addiction etc.) likely has an eating disorder (binge eating). This should not be a basis for denial of coverage. Putting these two condition for approval together and you have nothing but a hardened barrier to treatment that is not imposed on any other medical condition. If a person has an addiction to drugs or alcohol, most insurance companies provide in-patient coverage for detoxification and rehabilitation. Could you imagine if insurance made that coverage contingent on the addicts ability to prove they stayed off their drug of choice for 6 or more months before they would cover the cost of rehab??? In the case of obesity, diet and exercise alone does not work for the morbidly obese, so why impose a requirement that they lose 5-15% of their body weight as a condition for surgery. Worse yet, some carriers require patients to show they they failed a to lose 5% of their body weight after 6-24 months of supervised medical dieting. This creates a perverse incentive for a morbidly obese patient to go through counseling, but ignore the advice and not lose weight (all the while allowing their health to deteriorate). These types of requirements need to go. Do what you need to do to qualify for the surgery you need--but fight your ass off with the carrier if your denied coverage based on these arbitrary (but strictly enforced) requirements.

Good luck with your surgery. it's exciting--but that pre-op part is going to be the rough one for me. I'll make through when my time comes, but that's one of the hardest parts of the process as far as I can see. You're going to have to suffer a bit for a few months pre- and post-op, but I haven't met anyone who had surgery like this that didn't say it wasn't worth it in the end.

Here's what you can expect. You're going to be asked a serious of questions from either the HAMD or MADRS test for depression. You can look up samples online. A lot of people that suffer from obesity and have a BMI that qualifies them for surgery also suffer from depression. Many also have addictive personalities and abused food, drugs and/or alcohol in the past (or may be presently abusing). Having a history of depression or addiction does not disqualify you from surgery, but the psychologist need to show that you are being treated and that you can handle this procedure. They need to know that you have a support system in place to help you with this transition. Having this surgery is not going to cure all your problems--it's just going to make you thinner and PHYSICALLY healthier. If you gained weight because you have underlying issues, those issues need to be addressed (and you need to show that you are continuing to addressing them). That covers you for mood disorders, but they are also screening for other issues including personality disorders (borderline personality for example). People with borderline personality disorder (and other personality disorders) don't do very well with surgery or the changes that occur after surgery. If you are suffering schizophrenia, you may also have issues post-op. This will likely show up in your medical history, but you'll be screened anyway. If you have bi-polar depression, you can have problem coping with this surgery and many of the anti-psych drugs used to treat bi-polar depression cause weight gain, and that would need to be taken into consideration. I am not sure that any of these issues alone will disqualify you from surgery, but you're going to need to show that you're conditions (if you have one) is well controlled for at least a year and that your treating physician believes you are psychological prepared to handle the stress of surgery and the changes that it may bring. Aside from questions that are probing for the above issues, you'll be asked specific questions to determine whether you have considered the consequences of having this surgery and how it may effect your life. I would just answer these honestly. This is what I said in my interview (paraphrasing) 1. Why do want weight loss surgery? (asking to make sure you have realistic expectations and have a healthy outlook on this process) I don't want to have weight loss surgery. I wish I didn't need it, but I do need this surgery to become a healthier person. The cosmetic benefits are secondary. If the surgery just made me a healthy person, but I stayed just as fat as I am now, that would be fine too. However, that's not the way it works and I need to lose this weight to be healthy. Being fat is one thing, being sick and dead is another entirely. 2. If that's the case, Have you Tried Dieting and Exercise to lose the Weight? Absolutely, I have been dieting most of my adult life (or was between diets). i can lose weight, but keeping it off has been a problem. Most recently I went on a strict doctor supervised diet where I lost 40 pounds, but could never get below a certain point. I did everything by the book but just hit a plateau. After two months, it became frustrating and I started to slip. Within another 6 months, I gained back the 40 pounds I lost and then some. That's been the story of my life. Dieting and exercise just doesn't work for me or almost anyone that has more than 70 pounds to lose. That's not my opinion, that's what virtually every study shows. 3. Why do you think you gained this weight? Everyone is going to have a different answer, but in my case I gained the weight a little at a time. I was thin as a kid. Even in my early 20's, I worked out every day and watched what I ate. I even had a six pack for a while. Once I started working, that disappeared. I started gaining a few pounds every year. Then I would diet to lose the weight and it would creep back on quickly after I fell off the diet horse (with a few extra for good luck!). I am now 44, so if you take a normal person my height with a normal weight at 24 and add 4 pounds a year on average you end up being me. It wasn't noticeable at first, but it sneaks up on you and suddenly you realize you're the fattest guy in the room. (obviously, this doesn't apply to everyone--but that's how it happened for me). 4. Can you commit to changing your lifestyle after this surgery? Absolutely. It's not going to be easy. Nothing about this process is easy, but I either commit to change or I am going to have a very short life. I have two little girls and they need their daddy to walk them down the aisle when their time comes. I also need to do this for myself. I love being alive and I want to feel healthy again. 5. How does your family feel about you having this surgery? My wife is nervous, but supportive. My mom is behind this 100% and my dad is very nervous about it, but he supports me too. I have told anyone else in my family. I think they would support me, but I just don't feel like they need to know at that point in time. 6. This type of surgery can change the way you feel about yourself and the people around you. How do you think it will effect your relationship with your wife? I believe it will improve our relationship. My wife is a thin person, who watches what she eats. I know she loves me, but she's not happy that I am heavy and she is scared about the effects that being a diabetic may have for me. Being heavy (and diabetic) also can, in my case, cause sexual side effects for men and I think that losing the weight can only help me in that regard. I think you get the picture. Don't lie, but they want to know that you understand what you're getting into and will be able to handle the difficulties and changes that come from surgery. Good luck!

OP, I don't know your stats, but unless you have a thyroid condition or other serious metabolic issue (like taking high doses of insulin for type 2 diabetes), you should be able to drop 10 pounds in a month. It sounds like the problem here is that the amount you are being asked to lose is small enough that you might have blown off the diet until the last minute (sort of like cramming for an exam back in high school). I know you can lose the weight in time. Hell, I can lose 20 pounds in a month in I have to (although I also know I would gain 25 back afterwards). In the end, the surgery is just a tool and you're going to have to make some major lifestyle changes anyway if you are going to keep all weight off even after surgery. Now is a good time to start as any, Think positively and start practicing for you post-op diet now. Try cutting your portions down. Use bread plates instead of big plates for your meals. After you're done with your meal (normal size portions on a small plate, which is at least half veggies)---wait 20 minutes before you you give yourself seconds. I am not telling you not to eat more, but think about whether you are really hungry and whether you really need to have that extra portion. Is that extra portion really going to be worth it when it comes time for your weigh in. It's all about mindful eating. If you need to snack, make sure you have healthy snacks available--fruit and veggies without fattening dressings. Cut your food into small pieces (don't wolf it down). Put your fork down after every bite and chew each bite 15 times. It's annoying at first, but you get used to it (and you're going to need to do it anyway post-op). Also, the key to losing weight is drinking lots of water over the course of a day (at least 64oz) [that's always a hard one for me, but if you just sip on a water bottle a every few minutes you can do it). I am not on my high horse or anything---I admit to being a food addict, binge eater and sneak eater. So, no judgments from me, but if you want this surgery that badly, you will commit 100% to losing 10 pounds in 4 weeks and you will make it happen!!

Thanks so much for the responses guys. I guess there's a diverse view of this subject---which is why I am struggling to decide what's best for me. I don't think I have GERD. I do get heartburn every now and then (probably once every week or two), but it's not a constant and I think it's mostly a side effect of being on Victoza for type 2. The long term studies seem to suggest that people lose more weight with RNY and have less issues with regain after 5 years post-op. Patients that have either operation seem to have some regain, but the amount is significantly less with bypass. I don't think I have much concern about dumping syndrome (maybe I should be more concerned?). I don't have a sweet tooth. If given the choice between a piece of chocolate cake or a slice of pizza, I'll go with pizza every time (although obviously, that's not much better for you than the cake). My surgeon really didn't really tell me which procedure he thought would suit me best and sort of left it up to me (just explaining the pro's and con's of each). I guess I'll weight until the results are in from the rest of my pre-op screening consults with all the doctors on the list they gave me and then I'll have another conversation with the surgeon about this.