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What is your take on any type of artificial sweetener? I'm researching it, well, I just started, and I'm finding that artificial sweeteners (AS) in the end cause weight gain. I read an article on Dr. Oz's website about it, I tried to copy and paste to this message, but I don't know what I'm doing, so it's not here. I use a fair amount of AS, and I'm thinking I should stop. I have to admit, I'm addicted. It's an easy way to get "sweet" and not gain weight. And in my favorite, Iced coffee, it is sweeter than sugar. I'd have to use a LOT of sugar to equal my AS's sweetness. I hear it is bad for you. I want to use mostly natural foods in my diet, you are what you eat, right? So if you can give me your opinion on AS's, the pro's and con's, I'd feel good having your input. You guys know your stuff! If I'm going to be losing weight, I'd like to put the most nutritional, safest foods in my body. It can't be avoided completely, but I need to cut down. If you used AS's and stopped using them, or cut down....I gotta ask, HOW did you do it?

You might not be to tight, but you don't need a fill. Try the hot tea in the am, you still might not be able to do Breakfast but it might make lunch easier to deal with. Eat slower, chew more and chew some more. Also, if you have had the refund going on, try a couple days of liquids. Your throat might be swollen and is the cause of your problem. I am a strange band bird. Some days I can eat breakfast, most days I don't want it. Next, hot weather makes me tighter. Last summer it happened to me and daily I was making toilet deposits. Finally went to the doc and he said I had irritated my throat and should have done the liquids to let it repair. Unfill, weight gain because I was scared to refill. I have been told this is silly because our internal body temp remains the same. I haven't wanted food all day today, it was over 100 and I felt like nothing would go down if I tried. I had a Protein drink and for dinner 2 chicken strips. I haven't been hungry and have felt FULL the entire day. In fact I have felt this coming on for the past couple of weeks as the temps went up. I seldom am hungry and eat because I know I need to. It's hard sometimes because to me it's the same as stress eating. I usually don't want anything and will eat only the fun/wrong stuff.

Your body weight will fluctuate by several pounds on a daily basis. Many things can cause this fluctuation such as water weight gain, the clothes you wear, the time of day. Generally I weigh myself first thing in the morning, butt naked before breakfast. This tends to be my lowest weight. My clothes, coats and shoes can add 5 pounds to my weight. So generally the weight at the doctor's office is higher. The problem may also be due to your scale. After I had surgery, my scale was giving me all types of bad readings. I would step on the scale and weight myself and then repeat a couple seconds later and get a totally different reading, sometime a 5 pound difference. So I replaced my scale with one that was accurate to 0.2 pounds, repeatable readings, and a large visible backlit digital reading. I am half blind and since I weigh myself with my glasses off, it was difficult to step off the scale and bend down and read the results before the scale went off. Some digital scales will give erratic readings when the batteries are low.

You both did amazing!! I on the other hand did horrible. I have gained a total of 12 lbs in the last 2 months. I am starting over though. I went grocery shopping today and have made out my meal plan for all 3 meals a day for the next week. I find it much easier to stick to my diet when I plan. I have been going though alot of changes in my life over the last couple of months and know that has played a part in my weight gain as well. I feel like my life is starting to get back to normal and I want to get back into gear. I have been over 200 lbs since I was in elementary school and am almost 30 yrs old now. I can't wait to get in the 100's and know I will make it there soon. Congrats to you both!!

Yes, people can gain all their weight back. I see it all the time. The amount you can eat now won't be the amount you will be able to eat a year or two or five down the road. Some post ops can eat the equivalent of a small dinner plate of food years down the road. Why that happens is debatable, but it naturally happens with time. So a small dinner plate of high calorie fried food and mashed potatoes and gravy will have the same effect post op as it did pre op...weight gain. Grazing and drinking our calories is also a culprit of weight gain. Sure we may not be able to eat a lot in one sitting, but how easy is it to gulp down those 400 calorie coffees from Starbucks or eat a bag of chips through out the day? Heck, if you gave me enough time, I could probably polish off a whole pizza in a day

I don't know if this will help any of you waiting for Aetna approval. This is their policy on Bariatric Surgery: Clinical Policy Bulletin: Obesity Surgery Number: 0157 Policy Note: Most Aetna *** and QPOS plans exclude coverage of surgical operations, procedures or treatment of obesity unless approved by Aetna. Some Aetna plans entirely exclude coverage of surgical treatment of obesity. Please check benefit plan descriptions for details. Roux-en-Y Gastric Bypass (RYGB), Laparoscopic Adjustable Silicone Gastric Banding (LASGB), Sleeve Gastrectomy, Biliopancreatic Diversion (BPD) and Duodenal Switch (DS) Procedures: Aetna considers open or laparoscopic Roux-en-Y gastric bypass (RYGB), open or laparoscopic sleeve gastrectomy, open or laparoscopic biliopancreatic diversion (BPD) with or without duodenal switch (DS), or laparoscopic adjustable silicone gastric banding (LASGB) medically necessary when the selection criteria listed below are met. Selection criteria: Must meet either 1 (adults) or 2 (adolescents): For adults aged 18 years or older, presence of severe obesity that has persisted for at least the last 2 years (24 months), documented in contemporaneous clinical records, defined as any of the following: Body mass index (BMI) (see appendix) exceeding 40; or BMI greater than 35 in conjunction with any of the following severe co-morbidities: Clinically significant obstructive sleep apnea (i.e., person meets the criteria for treatment of obstructive sleep apnea set forth in CPB 0004 - Obstructive Sleep Apnea in Adults); or Coronary heart disease; or Medically refractory hypertension (blood pressure greater than 140 mmHg systolic and/or 90 mmHg diastolic despite concurrent use of 3 anti-hypertensive agents of different classes); or Type 2 diabetes mellitus [*] For adolescents who have completed bone growth (generally age of 13 in girls and age of 15 in boys), presence of obesity with severe co-morbidities: BMI exceeding 40 with one or more of the following serious co-morbidities: [*] BMI exceeding 50 with one or more of the following less serious co-morbidities: Medically refractory hypertension; or Hypertension; or Dyslipidemias; or Nonalcoholic steatohepatitis; or Venous stasis disease; or Significant impairment in activities of daily living; or Intertriginous soft-tissue infections; or Stress urinary incontinence; or Gastroesophageal reflux disease; or Weight-related arthropathies that impair physical activity; or Obesity-related psychosocial distress. [*]Member has attempted weight loss in the past without successful long-term weight reduction; and [*] Member must meet either criterion 1 (physician-supervised nutrition and exercise program) or criterion 2 (multi-disciplinary surgical preparatory regimen): Physician-supervised nutrition and exercise program: Member has participated in physician-supervised nutrition and exercise program (including dietician consultation, low calorie diet, increased physical activity, and behavioral modification), documented in the medical record at each visit. This physician-supervised nutrition and exercise program must meet all of the following criteria: or [*] Multi-disciplinary surgical preparatory regimen: Proximate to the time of surgery (within 6 months prior to surgery), member must participate in organized multi-disciplinary surgical preparatory regimen of at least 3 months (90 days) duration meeting all of the following criteria, in order to improve surgical outcomes, reduce the potential for surgical complications, and establish the member's ability to comply with post-operative medical care and dietary restrictions: Behavior modification program supervised by qualified professional; and Consultation with a dietician or nutritionist; and Documentation in the medical record of the member's participation in the multi-disciplinary surgical preparatory regimen at each visit. (A physician's summary letter, without evidence of contemporaneous oversight, is not sufficient documentation. Documentation should include medical records of the physician's initial assessment of the member, and the physician's assessment of the member's progress at the completion of the multi-disciplinary surgical preparatory regimen.); and Exercise regimen (unless contraindicated) to improve pulmonary reserve prior to surgery, supervised by exercise therapist or other qualified professional; and Program must have a substantial face-to-face component (must not be entirely delivered remotely); and Reduced-calorie diet program supervised by dietician or nutritionist. and [*] For members who have a history of severe psychiatric disturbance (schizophrenia, borderline personality disorder, suicidal ideation, severe depression) or who are currently under the care of a psychologist/psychiatrist or who are on psychotropic medications, pre-operative psychological clearance is necessary in order to exclude members who are unable to provide informed consent or who are unable to comply with the pre- and post-operative regimen. Note: The presence of depression due to obesity is not normally considered a contraindication to obesity surgery. [*] Vertical Banded Gastroplasty (VBG): Aetna considers open or laparoscopic vertical banded gastroplasty (VBG) medically necessary for members who meet the selection criteria for obesity surgery and who are at increased risk of adverse consequences of a RYGB due to the presence of any of the following co-morbid medical conditions: Demonstrated complications from extensive adhesions involving the intestines from prior major abdominal surgery, multiple minor surgeries, or major trauma; or Hepatic cirrhosis with elevated liver function tests; or Inflammatory bowel disease (Crohn's disease or ulcerative colitis); or Poorly controlled systemic disease (American Society of Anesthesiology (ASA) Class IV) (see Appendix); or Radiation enteritis. Aetna considers VBG experimental and investigational when medical necessity criteria are not met. [*] Repeat Bariatric Surgery: Aetna considers medically necessary surgery to correct complications from bariatric surgery, such as obstruction, stricture, erosion, or band slippage. Aetna considers repeat bariatric surgery medically necessary for members whose initial bariatric surgery was medically necessary (i.e., who met medical necessity criteria for their initial bariatric surgery), and who meet any of the following medical necessity criteria: Conversion to a RYGB or BPD/DS may be considered medically necessary for members who have not had adequate success (defined as loss of more than 50 % of excess body weight) 2 years following the primary bariatric surgery procedure and the member has been compliant with a prescribed nutrition and exercise program following the procedure; or Revision of a primary bariatric surgery procedure that has failed due to dilation of the gastric pouch or dilation of the gastrojejunostomy anastomosis is considered medically necessary if the primary procedure was successful in inducing weight loss prior to the dilation of the pouch or GJ anastomosis, and the member has been compliant with a prescribed nutrition and exercise program following the procedure; or Replacement of an adjustable band due to complications (e.g., port leakage, slippage) that can not be corrected with band manipulation or adjustments. [*] Experimental and Investigational Bariatric Surgical Procedures: Aetna considers each of the following procedures experimental and investigational because the peer reviewed medical literature shows them to be either unsafe or inadequately studied: Bariatric surgery as a treatment for idiopathic intracranial hypertension Gastroplasty, more commonly known as “stomach stapling” (see below for clarification from vertical band gastroplasty) Intragastric balloon Laparoscopic gastric plication LASGB, RYGB, and BPD/DS procedures not meeting the medical necessity criteria above Loop gastric bypass Mini gastric bypass Roux-en-Y gastric bypass as a treatment for gastroesophageal reflux in non-obese persons Silastic ring vertical gastric bypass (Fobi pouch) Transoral endoscopic surgery (e.g., the StomaphyX device/procedure) VBG, except in limited circumstances noted above. Cholecystectomy: As a high incidence of gallbladder disease (28 %) has been documented after surgery for morbid obesity, Aetna considers routine cholecystectomy medically necessary when performed in concert with elective bariatric procedures. Note: Bariatric surgery is considered experimental and investigational as a treatment for infertility (ACOG, 2009). See also CPB 0039 - Weight Reduction Medications and Programs. Background These criteria were adapted from the NIH Consensus Conference on Surgical Treatment of Morbid Obesity (1998) which state that obesity surgery should be reserved only for patients who have first attempted medical therapy: “Weight loss surgery should be reserved for patients in whom efforts at medical therapy have failed and who are suffering from the complications of extreme obesity.” Rationale for Pre-surgical Preparatory Regimen: The patient’s ability to lose weight prior to surgery makes surgical intervention easier and also provides an indication of the likelihood of compliance with the severe dietary restriction imposed on patients following surgery. Given the importance of patient compliance on diet and self-care in improving patient outcomes after surgery, the patient’s refusal to even attempt to comply with a nutrition and exercise regimen prior to surgery portends poor compliance with nutritional and self-care requirements after surgery. Therefore, the appropriateness of obesity surgery in non-compliant patients should be questioned. The patient must be committed to the appropriate work-up for the procedure and for continuing long-term post-operative medical management, and must understand and be adequately prepared for the potential complications of the procedure. There is rarely a good reason why obese patients (even super obese patients) can not delay surgery in order to undergo behavioral modification to improve their dietary and exercise habits in order to reduce surgical risks and improve surgical outcomes. The patient may be able to lose significant weight prior to surgery in order to improve the outcome of surgery. An individual’s understanding of the procedure and ability to comply with life-long follow-up and life-style changes (e.g., as exemplified by compliance with previous medical care) are necessary for the success of the procedure. Obesity makes many types of surgery more technically difficult to perform and hazardous. Weight loss prior to surgery makes the procedure easier to perform. Weight reduction reduces the size of the liver, making surgical access to the stomach easier. By contrast, the liver enlarges and becomes increasingly infiltrated with fat when weight is gained prior to surgery. A fatty liver is heavy, brittle, and more likely to suffer injury during surgery. Moreover, following surgery, patients have to follow a careful diet of nutritious, high-fiber foods in order to avoid nutritional deficiencies, dumping syndrome, and other complications. The total weight loss from surgery can be enhanced if it is combined with a low-calorie diet. For these reasons, it is therefore best for patients to develop good eating and exercise habits before they undergo surgery. The pre-operative surgical preparatory regimen should include cessation counseling for smokers. The National Institutes of Health Consensus Statement (1998) states that all smokers should be encouraged to quit, regardless of weight. Smoking cessation is especially important in obese persons, as obesity places them at increased risk for cardiovascular disease. Severely obese persons are at increased risk of surgical complications. Smoking cessation reduces the risk of pulmonary complications from surgery. Ideally, the surgical center where surgery is to be performed should be accomplished in bariatric surgery with a demonstrated commitment to provide adequate facilities and equipment, as well as a properly trained and funded appropriate bariatric surgery support staff. Minimal standards in these areas are set by the institution and maintained under the direction of a qualified surgeon who is in charge of an experienced and comprehensive bariatric surgery team. This team should include experienced surgeons and physicians, skilled nurses, specialty-educated nutritionists, experienced anesthesiologists, and, as needed, cardiologists, pulmonologists, rehabilitation therapists, and psychiatric staff. The American College of Surgeons (ACS) has stated that the surgeon performing the bariatric surgery be committed to the multidisciplinary management of the patient, both before and after surgery. The ACS recommended: "They develop skills in patient education and selection and are committed to long-term patient management and follow-up. There is active collaboration with multiple patient care disciplines including nutrition, anesthesiology, cardiology, pulmonary medicine, orthopedic surgery, diabetology, psychiatry, and rehabilitation medicine. Appropriate technical skills in the performance of bariatric surgical procedures are acquired." Although not a requirement for coverage, ideally, the bariatric surgeon should be board certified by the American Board of Surgery or in the process of certification within 5 years after completion of an accredited residency program in general or gastrointestinal surgery, and recertification has been obtained by the American Board of Surgery on an every 10-year basis, if applicable. Appropriate qualifications for a bariatric surgeon include either fellowship training or extended mentoring by an experienced surgeon, preferably by members of international/national bariatric societies, in all aspects of bariatric surgery, advanced laparoscopic techniques, and additional training in re-operative techniques. A number of studies have demonstrated a relationship between surgical volumes and outcomes of obesity surgery. Most recently, an assessment by the Canadian Agency for Drugs and Technologies in Health (CADTH) (Klarenbach et al, 2010) stated that their volume-outcome review found that higher surgical volumes were associated with better clinical outcomes. CADTH was not, however, able to identify specific thresholds for surgical volume that were associated with better clinical outcomes. A Multidisciplinary Care Task Group (Saltzman et al, 2005) conducted a systematic review of the literature to to provide evidence-based guidelines for patient selection and to recommend the medical and nutritional aspects of multi-disciplinary care required to minimize peri-operative and post-operative risks in patients with severe obesity who undergo weight loss surgery. The Task Group recommended multi-disciplinary screening of weight loss surgery patients to ensure appropriate selection; pre-operative assessment for cardiovascular, pulmonary, gastrointestinal, endocrine, and other obesity-related diseases associated with increased risk for complications or mortality; pre-operative weight loss and cessation of smoking; peri-operative prophylaxis for deep vein thrombosis and pulmonary embolism (PE); pre-operative and post-operative education and counseling by a registered dietitian; and a well-defined post-surgical diet progression. The authors explained that obesity-related diseases are often undiagnosed before weight loss surgery, putting patients at increased risk for complications and/or early mortality. Multi-disciplinary assessment and care to minimize short- and long-term risks include: comprehensive medical screening; appropriate pre-, peri-, and post-operative preparation; collaboration with multiple patient care disciplines (e.g., anesthesiology, pulmonary medicine, cardiology, and psychology); and long-term nutrition education/counseling. A Multidisciplinary Care Task Group (Saltzman et al, 2005) recommended that operative candidates must be committed to the appropriate work-up for the procedure and to continued long-term post-operative medical management. They must also be able to understand, and be adequately prepared for, potential complications. The Multidisciplinary Care Task Group recommended the use of patient selection criteria from the NIH Consensus Development Conference on Gastrointestinal Surgery for Severe Obesity, which are consistent with those of other organizations. These include: BMI greater than or equal to 40 kg/m2 or BMI greater than or equal to 35 kg/m2 in the presence of significant co-morbidities, a well-informed and motivated patient with a strong desire for substantial weight loss, failure of non-surgical approaches to long-term weight loss, and acceptable operative risks. The Task Group recommended that all weight loss surgery patients be encouraged to lose weight before surgery, and to promote 5 to 10 % pre-operative weight loss in patients with a BMI greater than 50 kg/m2 or obesity-related comorbidities (Saltzman et al, 2005). The Task Group recommended to decide on a case-by-case basis whether to proceed with surgery in patients who are unable to lose weight. The Task Group stated that registered dietitians are best qualified to provide nutritional care, including pre-operative assessment and post-operative education, counseling, and follow-up. Weight loss surgery patients need to learn important new skills, including self-monitoring and meal planning. Many forms of weight loss surgery require patients to take lifelong nutritional supplements and to have lifelong medical monitoring. Dedicated dietitians can help patients during their pre-operative education on new dietary requirements and stipulations and their post-surgical adjustment to those requirements. The Task Group also recommended a pre-operative assessment for micronutrient deficiencies. The Task Group recommended that smokers should be encouraged to stop, preferably at least 6 to 8 weeks before surgery (Saltzman et al, 2005). Bupropion and/or nicotine replacements are recommended to help minimize weight gain associated with smoking cessation. Patients should be encouraged to remain non-smokers after weight loss surgery to reduce the negative long-term health effects of smoking. Body Mass Index as a Criterion for Candidacy for Obesity Surgery: Surgery for severe obesity is usually considered an intervention of last resort with patients having attempted other forms of medical management (such as behavior change, increased physical activity and drug therapy) but without achieving permanent weight loss (Colquitt et al, 2002; NIH, 1995). Surgery is indicated for persons with severe obesity (body mass index (BMI) of 40 kg/m2 or more) or for persons with a BMI of 35 kg/m2 or more and serious co-morbidities such as diabetes, coronary heart disease, or obstructive sleep apnea. Ideally patients selected for surgery should have no major perioperative risk factors, a stable personality, no eating disorders, and have lost some weight prior to surgery. The patient's ability to lose weight prior to surgery makes surgical intervention easier and also provides an indication of the likelihood of compliance with the severe dietary restriction imposed on patients following surgery. Rationale for Six-Month Nutrition and Exercise Program Prior to Surgery: The NIH Consensus Conference on Surgical Treatment of Morbid Obesity (1998) states that obesity surgery should be reserved only for patients who have first attempted medical therapy: “Weight loss surgery should be reserved for patients in whom efforts at medical therapy have failed and who are suffering from the complications of extreme obesity.” The NIH Consensus Conference states that the initial goal of medical therapy is a 10 % reduction in weight, and that a reasonable duration for medical therapy is 6 months. The Consensus Conference stated: “The initial goal of weight loss therapy is to reduce body weight by approximately 10 % from baseline. If this goal is achieved, further weight loss can be attempted, if indicated through further evaluation. A reasonable time line for a 10 % reduction in body weight is 6 months of therapy.” The NIH Consensus Conference Statement (1998) explained "The rationale for this initial goal is that even moderate weight loss, i.e., 10 % of initial body weight, can significantly decrease the severity of obesity-associated risk factors." The NIH Consensus Conference (1998) states that the combination of a reduced calorie diet and increased physical activity can result in substantial improvements in blood pressure, glucose tolerance, lipid profile, and cardiorespiratory fitness. The NIH Consensus Conference (1998) has stated that the patient should begin a nutrition and exercise program prior to surgery: “An integrated program must be in place to provide guidance on diet, physical activity, and behavioral and social support both prior to and after the surgery.” The American Dietetic Association (1997), in their position statement obesity surgery, recommends dietetic counseling and behavioral modification commencing prior to, not after, surgery: “Careful dietetics evaluation is needed to determine if the patient will be able to comply with the postoperative diet. A preoperative behavior change program with psychological evaluation should be required.” More recently, evidence-based guidelines from the Scottish Intercollegiate Guidelines Network (2010) have stated that bariatric surgery should be considered on an individual case basis following assessment of risk/benefit in obese patients with "evidence of completion of a structured weight management programme involving diet, physical activity, psychological and drug interventions, not resulting in significant and sustained improvement in the comorbidities." Candidates for obesity surgery should begin a weight reduction diet prior to surgery. The purpose of a pre-operative nutrition program prior to obesity surgery are to test patient motivation, to reduce perioperative morbidity, to accustom patients to the restriction of food intake after surgery, and to increase total weight loss (van de Weijgert et al,1999; Jung and Cusciheri, 2000; Pekkarinen et al, 1997; Martin et al, 1995). Even super obese patients (BMI greater than 50) may benefit from initiating a nutrition and exercise program prior to surgery. Obesity itself increases the likelihood of pulmonary complications and wound infections (Choban et al, 1995; Abdel-Moneim, 1985; Holley et al, 1990; Myles et al, 2002; Nair et al, 2002; Bumgardner et al, 1995; Perez et al, 2001; Chang et al, 2000; Printken et al, 1975). The higher the patient's BMI, the higher the surgical risk, and the highest risks occur among patients with a BMI over 50 (Gonzalez et al, 2003; Oelschlager and Pellegrini, 2003). Even relatively modest weight loss prior to surgery can result in substantial improvements in pulmonary function, blood glucose control, blood pressure, and other physiological parameters (Anderson et al, 2000; Hakala et al, 1995; Kansanen et al, 1998; Pekkarinen et al, 1998). Factors such as blood glucose control, hypertension, etc., affect surgical risk. Garza (2003) explained that the patient should lose weight prior to surgery to reduce surgical risks. "The overall health of patients should be optimized prior to surgery to reduce the potential for complications. Patients ought to be encouraged to lose as much weight as possible before surgery" (Garza, 2003). Although the long-term effectiveness of weight reduction programs has been questioned, the Institute of Medicine (1995) has reported the substantial short-term effectiveness of certain organized physician-supervised weight reduction programs. For maximal benefit, dieting should occur proximal to the time of surgery, and not in the remote past to reduce surgical risks and improve outcomes. Even if the patient has not been able to keep weight off long-term with prior dieting, the patient may be able to lose significant weight short term prior to surgery in order to improve the outcome of surgery. Given the importance of patient compliance in diet and self-care in improving patient outcomes after surgery, the appropriateness of obesity surgery in noncompliant patients should be questioned. The American College of Surgeons has stated: “Not all persons who are obese or who consider themselves overweight are candidates for bariatric surgery. These procedures are not for cosmesis but for prevention of the pathologic consequences of morbid obesity. The patient must be committed to the appropriate work-up for the procedure and for continuing long-term postoperative medical management, and understand and be adequately prepared for the potential complications of the procedure. Screening of the patients to ensure appropriate selection is a critical responsibility of the surgeon and the supporting health care team.” A Multidisciplinary Care Task Group (Saltzman et al, 2005) conducted a systematic review of the literature and recommended an attempt at modest weight loss before obesity surgery, citing evidence that modest reductions in weight (5 to 10 % of initial weight) reduce factors known to increase surgical risk (e.g., sleep disordered breathing, hypertension, hyperglycemia), and that with weight loss, obese patients had significantly shorter operating room times and length of stay. The Task Group stated that registered dietitians are best qualified to provide nutritional care, including pre-operative assessment and nutritional education and counseling. Contraindications to Obesity Surgery: Surgery for severe obesity is a major surgical intervention with a risk of significant early and late morbidity and of perioperative mortality (Colquitt, 2002; Oelschlager and Pellegrini, 2003). Contraindications for these surgical procedures include peri-operative risk of cardiac complications, poor myocardial reserve, significant chronic obstructive airways disease or respiratory dysfunction, non-compliance of medical treatment, psychological disorders of a significant degree that a psychologist/psychiatrist would have thought would be exacerbated or interfere with the long-term management of the patient after the operation, significant eating disorders, or severe hiatal hernia/gastroesophageal reflux. A Multidisciplinary Care Task Group (Saltzman et al, 2005) identified contraindications to weight loss surgery, including unstable or severe coronary artery disease, severe pulmonary disease, portal hypertension with gastric or intestinal varices, and/or other conditions thought to seriously compromise anesthesia or wound healing. The Task Group also noted that weight loss surgery is contraindicated in those who are unable to comprehend basic principles of weight loss surgery or follow operative instructions. The Task Group stated that any combination of the following factors -- revisional surgery, male, greater than 50 years of age, BMI greater than 50 kg/m2, and obstructive sleep apnea, hypertension, and type 2 diabetes -- indicates high risk. Requirement that Obesity be Longstanding (Present for 2 or More Years): Obesity surgery is not indicated for persons with transient increases in weight (Collazo-Clavell, 1999). According to the Guidelines of the American Association of Clinical Endocrinologists and the American College of Endocrinology (1998), “Surgical treatment of obesity may be considered only in carefully selected patients [where] … obesity has been present for at least 5 years.” Obesity Surgery in Children and Adolescents: According to available guidelines, obesity surgery is generally indicated for persons age 18 and older (AACE, 1998). Children and adolescents are rapidly growing, and are therefore especially susceptible to adverse long-term consequences of nutritional deficiencies from the reduced nutrient intake and malabsorption that is induced by obesity surgery. It is not known whether the benefits of obesity surgery in children and adolescents outweigh the increased risks. According to a panel of experts (Inge et al, 2004; Lawson et al, 2006), bariatric surgery may be an appropriate treatment for severe obesity in adolescents who have completed bone growth. According to the recommendations by the expert panel, potential candidates for bariatric surgery should be referred to centers with multi-disciplinary weight management teams that have expertise in meeting the unique needs of overweight adolescents. Consideration for bariatric surgery is generally warranted only when adolescents have experienced failure of 6 months of organized weight loss attempts and have met certain criteria: severe obesity (a BMI of 40) and severe co-morbidities, or super obesity (BMI of 50) and less severe co-morbidities that may be remedied with weight loss; and have attained a majority of skeletal maturity (generally 13 years of age for girls and 15 years of age for boys). Surgery should only be performed at facilities that are equipped to collect long-term data on clinical outcomes. The panel recommended the Roux-en-Y gastric bypass method of surgery over the simpler, newer technique of implanting an adjustable gastric band since gastric bands are less effective and younger patients would probably need replacement as they age. Requirement for Physician Supervision of Program Documented in Medical Record: Aetna’s policy states that the patient should participate in a medically supervised nutrition and exercise program and/or a comprehensive multidisciplinary preoperative preparatory regimen, and that this participation be documented in the medical record. As is true generally, physicians should document their assessment of the patient, what health interventions are prescribed, and their assessment of the patient’s progress. There is established evidence that medical supervision of a nutrition and exercise program increases the likelihood of success (Blackburn, 1993). The American Medical Association Council on Scientific Affairs recommends that “any person considering a weight loss program first consult a physician for a physical examination and an objective evaluation of the proposed weight loss program as it relates to the individual’s physical condition … Various health organizations recommend that physicians assess their patients for overweight and that patients receive appropriate counseling about safe weight management and the benefits of physical activity and a healthy diet [citing guidelines from the National Heart, Lung and Blood Institute, the AACE/ACE, the Institute of Medicine of the National Academy of Sciences, the U.S. Preventive Services Task Force, the American Obesity Association, the American Medical Association, and an expert committee of pediatric experts convened by the Health Resources and Services Administration]” (Lyznicki et al, 2001). “If treatment is indicated, physicians can help patients develop weight loss or management plans tailored to individual needs; this includes setting reasonable weight loss goals; selecting appropriate weight loss programs; referring patients to ancillary personnel when appropriate; and providing monitoring, support and encouragement” (Lyznicki et al, 2001). Requirement for Psychological Evaluation: Candidates for obesity surgery who have a history of severe psychiatric disturbance (schizophrenia, borderline personality disorder, suicidal ideation, severe depression) or who are currently under the care of a psychologist/psychiatrist or who are on psychotropic medications should undergo a comprehensive evaluation by a licensed psychologist or psychiatrist to assess the patient’s suitability for surgery, the absence of significant psychopathology that can limit an individual’s understanding of the procedure or ability to comply with life-long follow-up (e.g., defined noncompliance with previous medical care, active substance abuse, schizophrenia, borderline personality disorder, uncontrolled depression). Roux-en-Y Gastric Bypass (RYGB) and Vertical Banded Gastroplasty (VBG): Surgery for obesity, termed bariatric surgery, includes gastric restrictive procedures and gastric bypass. The gastric restrictive procedures include vertical banded gastroplasty accompanied by gastric banding which attempt to induce weight loss by creating an intake-limiting gastric pouch by segmenting the stomach along its vertical axis. The process of digestion is more or less normal. In the United States, the primary operative choice for severely obese patients has recently shifted from vertical banded gastroplasty (VBG) to the Roux-en-Y gastric bypass (RYGB) (Fisher and Schauer, 2002; Mason et al, 1997). Vertical banded gastroplasty (VBG), a purely restrictive procedure, has fallen into disfavor because of inadequate long-term weight loss. Roux-en-Y gastric bypass (RYGB) combines restriction and malabsorption principles, and combines gastric segmentation along its vertical axis with a Roux-en-Y procedure, such that the food bypasses the duodenum and proximal small bowel. Because the normal flow of food is disrupted, available literature indicates that there is a greater potential for metabolic complications compared to gastric restrictive surgeries, including Iron deficiency anemia, Vitamin B-12 deficiency and hypocalcemia, all of which can be corrected by oral supplementation. Several studies have suggested that RYGB is a more effective weight loss procedure than VBG, offering the best combination of maximum weight control and minimum nutritional risk (Sugerman et al, 1989; Howard et al, 1995). Pories et al (1995) reported 57.7 %, 54.7 %, and 49.2 % excess weight loss with RYGB at 5, 10, and 14 years, respectively, in a large series with 95 % follow-up. Thus, the RYGB is "the current procedure of choice for patients requiring surgery for morbid obesity" (Barrow; 2002). An assessment conducted by the French National Technology Assessment Agency (ANAES, 2001; Msika, 2003) found that surgical mortality for RYGB and VBG is about the same. However, RYGB is associated with significantly more weight loss, and has become the procedure of choice for obesity surgery. Gentileschi et al (2002) systematically reviewed the published literature on open and bariatric laparoscopic obesity surgery and concluded that the available evidence indicates that laparoscopic VBG and laparoscopic RYGB are as effective as their open counterparts. An assessment of laparoscopic RYGB by the BlueCross BlueShield Association Technology Evaluation Center (BCBSA, 2005) stated that among available bariatric surgical procedures, RYGB appears to have the most favorable risk-to-benefit ratio, and that the overall risk-to-benefit ratio of laparoscopic RGBY is similar to that of open RGBY. The assessment found that open and laparoscopic RYGB induces similar amounts of weight loss. However, the assessment found that the profile of adverse events differs between the two approaches. Laparoscopic RYGB is a less invasive approach that results in a shorter hospital stay and earlier return to usual activities. The assessment found that the estimated mortality rate was low for both procedures, but somewhat lower for laparoscopic surgery than open surgery (0.3 % versus 1.1 %). Laparoscopic RGBY had a higher rate of postoperative anastomotic leaks than open RGBY (3.7 % versus 1.9 %), and a somewhat higher rate of bleeding (4.1 % versus 2.4 %). The report found, on the other hand, that open surgery had higher rates of cardiopulmonary complications (2.6 % versus 1.0 %) and wound infections (11.0 % versus 4.7 %). Regarding long-term adverse events, the rates of reoperation (9.9 %) and anastomotic problems (8.0 %) may be higher for laparoscopic RGBY than for open RGBY (6.0 % and 2.0 %, respectively), while the rate of incisional hernia is higher for open RGBY than laparoscopic RGBY (9.0 % versus 0 %). An assessment by the Institute for Clinical Systems Improvement (ICSI, 2005) found that large studies have shown that RYGB may result in weight loss of 60 % to 70 % of excess weight. It also found that VBG shows substantial weight loss efficacy but less than that for RYGB. In addition, VBG has a high rate of serious morbidity, including a re-operation rate of up to 30 % from stoma obstruction and staple-line disruption. Therefore, the evidence supports the overall superiority of RYGB over VBG in safety and efficacy for bariatric surgery. A decision memorandum from the Centers for Medicare and Medicaid Services (CMS, 2006) concluded that the evidence is sufficient that open and laparoscopic RYGB is reasonable and necessary for Medicare beneficiaries who have a BMI greater than 35 and have at least one co-morbidity related to obesity, and have been previously unsuccessful with medical treatment for obesity. The assessment concluded that the evidence is not adequate to conclude that open or laparoscopic vertical banded gastroplasty is reasonable and necessary and they are therefore non-covered for all Medicare beneficiaries. A systematic evidence review by the Canadian Agency for Drugs and Technologies in Health (CADTH) (Klarenbach et al, 2010) found that, although data from large, adequately powered, long-term randomized controlled trials are lacking, bariatric surgery seems to be more effective than standard care for the treatment of severe obesity in adults. Procedures that are mainly diversionary (e.g., biliopancreatic diversion (BPD)) result in the greatest amounts of weight loss, hybrid procedures are of intermediate effectiveness (e.g., RYGB), and restrictive procedures (e.g., adjustable gastric banding) result in the least amounts of weight loss. RYGB and adjustable gastric banding tended to lead to trade-offs between the risk of adverse events and the need for procedure conversion or reversals. Biliopancreatic Diversion (BPD) (Jejunoilieal Bypass, Scorpinaro Procedure) and Duodenal Switch (DS) Procedures: While appropriate surgical procedures for severe obesity primarily produce weight loss by restricting intake, intestinal bypass procedures produce weight loss by inducing a malabsorptive effect. Biliopancreatic bypass or diversion (BPD) (also called jejunoileal bypass or the Scopinaro procedure) consists of a subtotal gastrectomy and diversion of the biliopancreatic juices into the distal ileum by a long Roux-en-Y procedure; the result is a 200-cm long alimentary tract, a 300- to 400-cm biliary tract, and after these 2 tracts are joined at the distal anastomosis, there is a 50-cm common absorptive alimentary tract. The BPD was designed to address some of the drawbacks of the original intestinal bypass procedures, which resulted in unacceptable metabolic complications of diarrhea, hyperoxaluria, nephrolithiasis, cholelithiasis and liver failure. The duodenal switch (DS) is a variant of the BPD procedure with a vertical subtotal gastrectomy and pylorus preservation, which eliminates the "dumping syndrome". The duodenum is divided just beyond the pylorus. The small bowel is then divided, and the end going to the cecum of the colon is connected to the short stump of the duodenum. This becomes the "enteral limb". The other end, leading from the gallbladder and pancreatic ducts, is connected onto the enteral limb at about 75 to 100 cm from the iliocecal valve. This limb is the "biliopancreatic limb". The last 75-100 cm then becomes the "common channel", measuring about 10 % of the total small bowel length and is the only portion that can absorb fat. Some have advocated use of the DS procedure in the super-obese (i.e., persons with BMI greater than 50) because of the substantial weight loss induced by this procedure. Patients who have this operation must have lifelong medical follow-up, since the side effects can be subtle, and can appear months to years after the surgery. A decision memorandum from the Centers for Medicare and Medicaid Services (CMS, 2006) concluded that open or laparoscopic BPD with or without DS are reasonable and necessary for Medicare beneficiaries. Gastroplasty (“Stomach Stapling”): Gastroplasty, more commonly known as "stomach stapling" and not to be confused with vertical banded gastroplasty (VBG), is a technically simple operation, accomplished by stapling the upper stomach to create a small pouch into which food flows after it is swallowed. The outlet of this pouch is restricted by a band of synthetic mesh, which slows its emptying, so that the person having it feels full after only a few bites of food. According to the available literature, patients who have this procedure seldom experience any satisfaction from eating, and tend to seek ways to get around the operation by eating more. This causes vomiting, which can tear out the staple line and destroy the operation. Overall, clinical studies have shown that about 40 % of persons who have this operation do not achieve loss of more than half of their excess body weight. In the long-term, 5 or more years after surgery, only about 30 % of patients have maintained a successful weight loss. Studies have reported that many patients must undergo another revisional operation to obtain the results they seek. Sleeve Gastrectomy: Sleeve gastrectomy is a 70 to 80 % greater curvature gastrectomy (sleeve resection of the stomach) with continuity of the gastric lesser curve being maintained while simultaneously reducing stomach volume (CMS, 2005). It is often the first step in a 2-stage procedure when performing RYGB or duodenal switch. A decision memorandum from the Centers for Medicare and Medicaid Services (CMS) found that the data supporting open or laparoscopic sleeve gastrectomy are generally sparse and not adequate to draw conclusions. The CMS concluded, therefore, that these procedures are not reasonable and necessary for Medicare beneficiaries. The CMS decision memorandum stated that their conclusions about the lack of clinical data for sleeve gastrectomy applied, not only to the Medicare-aged population, but also to persons under 65 years of age. More recently, a systematic evidence review prepared for Clinical Evidence concluded that the effectiveness of sleeve gastrectomy for morbid obesity is unknown (DeLaet and Schauer, 2009). The evidence review found no clinically important results from randomized controlled clinical trials about sleeve gastrectomy compared with non-surgical treatment, or compared with vertical banded gastroplasty or biliopancreatic diversion. They found low quality evidence that sleeve gastrectomy may be more effective than gastric banding at increasing weight loss at 1 and 3 years, and moderate quality evidence that sleeve gastrectomy seems more effective than gastric bypass at increasing mean excess-weight loss at 1 to 2 years. A systematic evidence review of sleeve gastrectomy by the Australia and New Zealand Horizon Scanning Network (ANZHSN) (Lee, 2007) found that the evidence showed that laparoscopic sleeve gastrectomy can induce substantial excess weight loss at least as effectively as LASGB (in one study up to 3-years post surgery) but less effectively than gastric bypass and duodenal switch in the short-term. The report noted, however, that these results should be viewed in light of the ease and simplicity of laparoscopic sleeve gastrectomy relative to the other more invasive procedures. The report found a comparable reduction in co-morbidities in patients who underwent laparoscopic sleeve gastrectomy or RYGB, most notably in resolution rates of diabetes within 4 months after surgery despite laparoscopic gastric banding patients being significantly more obese than the RYGB patients in the study. Evidence suggested that, compared to LASGB, laparoscopic sleeve gastrectomy had lower complication rates but more severe complications. The report found laparoscopic sleeve gastrectomy safer than laparoscopic RYGB or intragastric balloon implantation. The report stated that evidence of the safety of laparoscopic sleeve gastrectomy compared with duodenal switch is conflicting possibly because of differences in baseline patient characteristics. The report stated that the incidence of gastric sleeve dilatation appears to be an uncommon event, but the evidence is far from conclusive at this point. The report noted that one study found that laparoscopic sleeve gastrectomy and LASGB had significantly shorter operative times compared to RYGB and duodenal switch. Laparoscopic sleeve gastrectomy had a significantly longer length of stay compared to LASGB, but a significantly shorter length of stay compared to RYGB and duodenal switch. The report found that knowledge gaps include: comparing the effectiveness of laparoscopic sleeve gastrectomy to established bariatric procedures in super-obese (BMI greater than or equal to 50) as a stand alone procedure; long-term (greater than 5 years) safety, durability of weight loss and comorbidity data for laparoscopic sleeve gastrectomy relative to existing bariatric procedures; and effects of laparoscopic sleeve gastrectomy on plasma ghrelin levels and subsequent effect on appetite. More recently, a review of the literature by the Veterans Health Administration Technology Assessment Program (Adams, 2008) found no new literature that would not alter the conclusions of the ANZHSN review. A randomized controlled clinical trial comparing short-term (1-year) outcomes of laparoscopic sleeve gastrectomy to laparoscopic RYGB found comparable reductions in body weight and BMI (Karamanakos et al, 2008). However, power calculations were not reported, and the study (n = 32) was likely under-powered to detect clinically signficant differences in effectiveness between the 2 procedures. This study was poorly reported, failing to discuss inclusion criteria for the trial and adverse events associated with the procedures. An earlier retrospective study by Lee et al (2007) (n = 846) found similar rates of short-term weight loss in persons who elected sleeve gastrectomy and persons who elected RYGB or duodenal switch procedures. However, the lack of randomization and retrospective nature of the study results in a substantial risk of bias in the results. The strongest arguments for sleeve gastrectomy relate to the comparatively poor outcomes of LASGB, which is the competing option for persons wishing to undergo a restrictive (non-malabsorptive) procedure. A randomized clinical study by Himpens et al (2006) compared laparoscopic sleeve gastrectomy to LASGB (n = 80). Although median weight loss was significantly greater after 1 and 3 years with sleeve gastrectomy (65 lbs) than with LASGB (37.5 lbs), the total weight loss with either procedure was insufficient for most potential candidates. The study also found that sleeve gastrectomy was associated with more severe complications than LASGB. The study was also poorly reported, including failure to discuss randomization and blinding procedures, and whether any subjects did not comply with randomization or were lost to follow-up. Clinical studies have reported long-term reoperation rates with LASGB of up to 60 % (see, e.g., Scozzari et al, 2009; Camerini et al, 2004; Tweddle et al, 2004; Morino et al, 2002). Australia has reported that the costs of band adjustments with LASGB has exceeded the costs of the primary LASGB procedure. A Cochrane review of the evidence for bariatric surgical procedures (Colquitt et al, 2009) found that, although the effects of the available bariatric procedures compared with medical management and with each other are uncertain, "limited" evidence suggests that sleeve gastrectomy results in weight loss similar to RYGB and greater than with LASGB. The assessment stated that information from the included trials did not allow the authors to reach any conclusions about the safety of these procedures compared with each other. The assessment noted that, due to limited evidence and poor quality of the trials comparing each pair of procedures, these conclusions should be viewed with caution. In a position statement, the American Society for Metabolic and Bariatric Surgery (2009) determined that sleeve gastrectomy is an "approved bariatric surgical procedure" despite finding only "limited" intermediate term data and a lack of long-term data on the effectiveness of the procedure. The ASMBS position statement explained that the Society has accepted sleeve gastrectomy as an approved bariatric surgical procedure primarily because of its potential value as a first-stage operation for high-risk patients, primarily super-obese patients with an average BMI of 60 kg/m2. The ASMBS reached this conclusion despite not knowing what proportion of super-obese patients will achieve satisfactory outcomes with sleeve gastrectomy alone without conversion to RYGB or duodenal switch, and despite a lack of evidence that accomplishing RYGB or duodenal switch as a staged procedure results in better outcomes (fewer risks) than accomplishing these procedures as a single surgery. An assessment by the California Technology Assessment Forum (CTAF) (Walsh, 2010) concluded that sleeve gastrectomy does not meet CTAF technology assessment criteria for improvement in health outcomes for the treatment of obesity. The CTAF assessment reported that the results of multiple case series and retrospective studies have suggested that sleeve gastrectomy as a primary procedure is associated with a significant reduction in excess weight loss. The CTAF assessment reported that the complication rate from sleeve gastrectomy ranged from 0 % to 4.1 % and complications included leaks, bleeding, strictures and mortality. The CTAF assessment found few comparative studies of sleeve gastrectomy. CTAF identified only 2 randomized controlled trials that have compared sleeve gastrectomy to another surgical procedure (citing Himpens et al, 2006; Karamanakos et al, 2008). These trials included a total of 112 participants who were followed from 1 to 3 years. Among the 80 subjects followed for 3 years, there were a similar number of complications in the sleeve gastrectomy and the RYGB groups, although the complications in the sleeve gastrectomy group were more severe. The CTAF assessment stated that, "[t]o date, long term outcomes from registry studies are relatively limited, but longer term follow-up will provide additional important information." An assessment of surgical treatment for obesity from the Canadian Agency for Drugs and Technologies in Health (CADTH) (Klarenbach et al, 2010) also concluded that the evidence base for sleeve gastrectomy is limited. Loop Gastric Bypass: Although the basic concept of gastric bypass remains intact, numerous variations are being performed at this time. Recent data demonstrate that surgeons are moving from simple gastroplasty procedures, favoring the more complex gastric bypass procedures as the surgical treatment of choice for the severely obese patient. The gastric bypass operation can be modified, to alter absorption of food, by moving the Roux-en-Y-connection distally down the jejunum, effectively shortening the bowel available for absorption of food. The weight loss effect is then a combination of the very small stomach, which limits intake of food, with malabsorption of the nutrients, which are eaten, reducing caloric intake even further. In a sense, this procedure combines the least desirable features of the gastric bypass with the most troublesome aspects of the biliopancreatic diversion. Although patients can have increased frequency of bowel movements, increased fat in their stools, and impaired absorption of Vitamins, recent studies have reported good results. The loop gastric bypass developed years ago has generally been abandoned by most bariatric surgeons as unsafe. Although easier to perform than the RYGB, it has been shown to create a severe hazard in the event of any leakage after surgery, and seriously increases the risk of ulcer forrmation, and irritation of the stomach pouch by bile. Laparoscopic Adjustable Silicone Gastric Banding (LASGB): Recent advances in laparoscopy have renewed the interest in gastric banding techniques for the control of severe obesity. Laparoscopic adjustable silicone gastric banding (LASGB) has become an attractive method because it is minimally invasive and allows modulation of weight loss. Available brands of LASGB include the Lap-Band System (Allergan, Inc., Irvine, CA) and the Realize Adjustable Gastric Band (Ethicon Endo-Surgery, Cincinnati, OH). The claimed advantage of LASGB is the adjustability of the band, which can be inflated or deflated percutaneously according to weight loss without altering the anatomy of the stomach. This method entails encircling the upper part of the stomach using bands made of synthetic materials, creating a small upper pouch that empties into the lower stomach through a narrow, non-stretchable stoma. The reduced capacity of the pouch and the restriction caused by the band diminish caloric intake, depending on important technical details, thus producing weight loss comparable to vertical gastroplasties, without the possibility of staple-line disruption and lesser incidence of infectious complications. However, distension of the pouch, slippage of the band and entrapment of the foreign material by the stomach have been described and are worrisome. A decision memorandum from the CMS (2006) found that there was sufficient evidence to support LASGB as reasonable and necessary for Medicare beneficiaries with a BMI greater than 35 and co-morbid medical conditions. Sustained weight loss was well documented, ranging from an approximate mean of 30 to 50 % excess weight loss in LASGB, compared to an approximate mean of 50 % excess weight loss in RYGB. The CMS decision memorandum found that short-and-long-term mortality associated with both LASGB and RYGB were low (less than 2 %) in this younger age group. Regarding performing adjustable gastric banding as an open procedure, the CMS decision memorandum (2006) concluded that the evidence is not adequate to conclude that open adjustable gastric banding is reasonable and necessary and therefore this procedure remains noncovered for Medicare beneficiaries. Mini Gastric Bypass: The "mini gastric bypass" has been promoted as a new surgical treatment for severe obesity. It involves laparoscopic construction of a large and elongated gastric pouch and a loop gastric bypass with distal diversion (200 cm or up to 50 % of the small bowel) to reduce food absorption. While the name mini gastric bypass implies "small" and "simple", this is a major surgical procedure. The mini-gastric bypass uses a jejunal loop directly connected to a small gastric pouch, instead of a Roux-en-Y anastomosis. In this way, the mini-gastric bypass is similar to the loop gastric bypass; the latter procedure that has been abandoned by bariatric surgeons because of its inherent risks. Specifically, performing a loop, rather than a Roux-en-Y, anastomosis to a small gastric pouch in the stomach may permit reflux of bile and digestive juice into the esophagus where it can cause esophagitis and ulceration, and may thus increase the risk of esophageal cancer. The Roux-en-Y modification of the loop bypass was designed to divert bile downstream, several feet below the gastric pouch and esophagus to minimize the risk of reflux. The trend towards use of Roux-en-Y and away from loop gastric bypass was based on sound surgical experience of multiple surgeons with large series of patients. The published evidence supporting the mini-gastric bypass comes from descriptive reports and case series; the potential biases inherent in reports of case series are well known in clinical epidemiology. The evidence for the mini gastric bypass has come from a single investigator, thus raising questions about the generalization and validity of the reported findings. The mini-gastric bypass has not been subjected to a prospective clinical outcome study in peer-reviewed publication. Silastic Ring Vertical Gastric Bypass (Fobi Pouch): The Fobi pouch, developed by California surgeon Mathias A.L. Fobi, is a modification of gastric bypass surgery. The modifications to gastric bypass surgery are designed to prevent post-surgical enlargement of the gastric pouch and stoma. In a traditional gastric bypass procedure, surgeons create a smaller stomach by stapling off a large section. A problem with the traditional procedure is that the staples can break down, causing the stomach to regain its original shape -- and patients to start gaining weight again. Also, the stomach opening that leads into the intestines, which in surgery is made smaller to allow less food to pass through, often stretches as the years go by. With the Fobi pouch, there is no use of staples; rather, the stomach is bisected and hand-sewn them to maintain the separation. A synthetic band is placed around the stomach opening to keep it from stretching. However, there is a paucity of direct comparative studies of the Fobi pouch to traditional gastric bypass surgery, causing colleagues to "question whether his technique is really an improvement on the traditional procedure" (Davis, 2000). All of the published literature has been limited to descriptive articles, case series, and a prospective non-randomized controlled study. These studies were from a single group of investigators, raising questions about the generalization of the findings. Intragastric Balloon: The intragastric balloon (also known as the silicone intragastric balloon or SIB) has been developed as a temporary aid for obese patients who have had unsatisfactory results in their clinical treatment for obesity and super obese patients with higher surgical (Fernandes et al, 2004). Intragastric balloon is intended to reduce gastric capacity, causing satiety, making it easier for patients to take smaller amounts of food. Randomized, controlled clinical studies, however, have found no increase in weight loss with the intragastric balloon plus dieting versus dieting alone (Rigaud et al, 1995; Geliebter et al, 1991; Mathus-Vliegen et al, 1990; Lindor et al, 1987). One non-randomized controlled clinical study that reported positive results reported that results were not maintained after gastric balloon removal (Ramhamadany et al, 1989). In addition, the intragastric balloon has been associated with potentially severe adverse effects, including gastric erosion, reflux, and obstruction. An assessment of the intragastric balloon from the Canadian Coordinating Office for Health Technology Assessment (2006) concluded that “[m]ore data on the benefits, harms, and cost-effectiveness are required before the intragastric balloon can be compared with other short-term weight loss interventions, including low-calorie diets.” StomaphyX: In March 2007, the FDA granted 510(k) pre-marketing clearance to the StomaphyX (EndoGastric Solutions, Inc.), an endoluminal fastener and delivery system used to tighten esophageal tissue. There is only limited evidence on the effectiveness of the StomaphyX in bariatric surgery repair/revision. Overcash (2008) reported 2 cases of the safe and successful use of the StomaphyX device to alter the flow of gastric contents and repair gastric leaks resulting from bariatric revision surgery. Both patients were at a high risk and could not undergo another open or laparoscopic surgery to correct the leaks that were not healing. The author reported that the StomaphyX procedures lasted approximately 30 mins, were performed without any complications, and resulted in the resolution of the gastric leaks in both patients. The findings of these cases needs to be validated by well-designed clinical studies. Bariatric Surgery and Pregnancy: The American College of Obstetricians and Gynecologists' practice bulletin on bariatric surgery and pregnancy (ACOG, 2009) stated that bariatric surgery should not be considered a treatment for infertility. Bariatric Surgery for the Treatment of Idiopathic Intracranial Hypertension: Fridley et al (2011) reviewed the literature on the effectiveness of bariatric surgery for obese patients with idiopathic intracranial hypertension (IIH) with regard to both symptom resolution and resolution of visual deficits. The published literature was reviewed using manual and electronic search techniques. Data from each relevant manuscript were gathered, analyzed, and compared. These included demographic data, pre- and post-operative symptoms, pre- and post-operative visual field deficits, bariatric procedure type, absolute weight loss, changes in body mass index, and changes in cerebrospinal Fluid (CSF) opening pressure. A total of 11 relevant publications (including 6 individual case reports) were found, reporting on a total of 62 patients. The Roux-en-Y gastric bypass was the most common bariatric procedure performed. Fifty-six (92 %) of 61 patients with recorded post-operative clinical history had resolution of their presenting IIH symptoms following bariatric surgery. Thirty-four (97 %) of 35 patients who had undergone pre- and post-operative funduscopy were found to have resolution of papilledema post-operatively. Eleven (92 %) of 12 patients who had undergone pre- and post-operative formal visual field testing had complete or nearly complete resolution of visual field deficits, and the remaining patient had stabilization of previously progressive vision loss. In 13 patients both pre- and post-operative CSF pressures were recorded, with an average post-operative pressure decrease of 254 mm H(2)O. Changes in weight loss and body mass index varied depending on the reported post-operative follow-up interval. The authors concluded that the published Class IV evidence suggested that bariatric surgery may be an effective treatment for IIH in obese patients, both in terms of symptom resolution and visual outcome. They stated that prospective, controlled studies are needed for better elucidation of its role. Laparoscopic Gastric Plication: Pujol Gebelli et al (20110 stated that laparoscopic gastric plication is a new technique derived from sleeve gastrectomy. Plication of the greater curvature produces a restrictive mechanism that causes weight loss. The results of the first cases where this technique has been applied in this hospital were presented. A review was made of patients operated on in the authors' hospital between November 2009 and December 2010. Plication of the gastric greater curvature was performed under general anesthetic and by laparoscopy using 3 lines of sutures and with an orogastric probe as a guide. Results of the morbidity, mortality and weight loss were presented. A total of 13 patients were operated on (7 women). The maximum BMI varied between 37.11 kg/m² and 51.22 kg/m² at the time of the operation. The most frequently found morbidity was nausea and vomiting. Two patients required further surgery due intractable vomiting and total dysphagia; in 1 the plication unfolded, and in the 2nd it was converted into vertical gastrectomy. The authors concluded that laparoscopic gastric plication is a new surgical technique which gives equivalent short-term results as vertical gastrectomy. It is a reproducible and reversible technique with results and indications still to be validated. Brethauer et al (2011) presented the results of a feasibility study using laparoscopic gastric plication for weight loss achieved without stapling or banding. After institutional review board approval, 2 methods were used to achieve laparoscopic gastric volume reduction. In the 1st group (anterior plication [AP]), the anterior gastric wall was folded inward from the fundus to the antrum using 2 rows of running sutures. The greater and lesser curvatures were approximated to create an intraluminal fold of the stomach. In the 2nd group (greater curvature plication [GCP]), the short gastric vessels were divided, and the greater curvature was folded inward, with 2 suture lines to reduce the gastric capacity by a large intraluminal gastric fold. The average pre-operative body mass index was 43.3 kg/m(2) (range of 36.9 to 49.0), and 3 patients were men. Of the 15 patients, 9 underwent AP. For the 9 patients who underwent AP, the 6- and 12-month endoscopic evaluations demonstrated comparable-size plications over time, except for in 1 patient, who had a partially disrupted fold. Of the 6 patients who underwent GCP, the 6- and 12-month follow-up endoscopic examinations demonstrated a durable intraluminal fold, except for in 1 patient, with a partial disruption at the distal fold owing to a broken suture. For patients completing 1 year of follow-up, the percentage of excess weight loss was 23.3 % +/- 24.8 % in the AP group (n = 5) and 53.4 % +/- 22.7 % in the GCP group (n = 6). No bleeding or infectious complications developed. The 1st patient in the GCP group required re-operation and plication reduction owing to gastric obstruction. The authors concluded that their initial experience has suggested that a reduction in gastric capacity can be achieved by way of plication of the anterior stomach and greater curvature. The early weight loss results have been encouraging, with better weight loss in patients who underwent GCP. They stated that the use of laparoscopic GCP warrants additional investigation as a primary bariatric procedure. Huang et al (2012) noted that the laparoscopic adjustable gastric band has been widely accepted as 1 of the safest bariatric procedures to treat morbid obesity. However, because of variations in the results and the complications that tend to arise from port adjustment, alternative procedures are needed. These researchers have demonstrated, in a university hospital setting, the safety and feasibility of a novel technique, laparoscopic adjustable gastric banded plication, designed to improve the weight loss effect and decrease gastric band adjustment frequency. These investigators enrolled 26 patients from May 2009 to August 2010. Laparoscopic adjustable gastric banded plication was performed using 5-port surgery. They placed Swedish bands using the pars flaccida method, divided the greater omentum, and performed gastric plication below the band to 3 cm from the pylorus using a single-row continuous suture. The data were collected and analyzed pre- and post-operatively. The mean operative time was 87.3 mins without any intra-operative complications. The average post-operative hospitalization was 1.33 days. The mean excess weight loss at 1, 3, 6, 9, and 12 months after surgery was 21.9 %, 31.9 %, 41.3 %, 55.2 %, and 59.5 %, respectively. The mean follow-up time was 8.1 months (range of 2 to 15), and the gastric band adjustment rate was 1.1 times per patient during this period. Two complications developed: (i) gastrogastric intussusception and (ii) tube kinking at the subcutaneous layer. Both cases were corrected by reoperation. No mortality was observed. The authors concluded that laparoscopic adjustable gastric banded plication provides both restrictive and reductive effects and is reversible. The technique is safe, feasible, and reproducible and can be used as an alternative bariatric procedure. Moreover, the authors stated that comparative studies and long-term follow-up are needed to confirm their findings. Member's participation in a physician-supervised nutrition and exercise program must be documented in the medical record by an attending physician who supervised the member's participation. The nutrition and exercise program may be administered as part of the surgical preparative regimen, and participation in the nutrition and exercise program may be supervised by the surgeon who will perform the surgery or by some other physician. Note: A physician's summary letter is not sufficient documentation. Documentation should include medical records of physician's contemporaneous assessment of patient's progress throughout the course of the nutrition and exercise program. For members who participate in a physician-administered nutrition and exercise program (e.g., MediFast, OptiFast), program records documenting the member's participation and progress may substitute for physician medical records; and Nutrition and exercise program must be supervised and monitored by a physician working in cooperation with dieticians and/or nutritionists, with a substantial face-to-face component (must not be entirely remote);and Nutrition and exercise program(s) must be for a cumulative total of 6 months (180 days) or longer in duration and occur within 2 years prior to surgery, with participation in one program of at least 3 consecutive months. (Precertification may be made prior to completion of nutrition and exercise program as long as a cumulative of 6 months participation in nutrition and exercise program(s) will be completed prior to the date of surgery.) Clinically significant obstructive sleep apnea; or Type 2 diabetes mellitus; or Pseudotumor comorbidities

I was right dam it!!! My doctor and the program neglected me. . I began to look toward the low carb diets when I found the answer in the Atkins book when I read taking beta-blockers will greatly hinder weight loss. Dr. Yarsbrough failed to even read my records to see I was taking Propranolol, a beta-blocker that is known to cause weight gain. I went to him for help and he destroyed my self esteem, degraded me ( by telling me I don’t know myself), demeaned me ( by laughing at me) and neglected to help me ( never looked at my records to see I was taking a beta blocker). Each question this doctor asked me, he nailed to the wall to fish an answer to why I wasn’t losing weight and how it can be blamed on me. He was very cruel and would like to stop him from doing this to others. If I did give up, I would'nt of found the solution. I am now back on track baby!! Because of the beta-blocker, I am the same weight I was two months ago, I found the answer.

It's official. I gained 6 lbs since my "unfill" on March 10. It's probably not a full 6 lbs because I'm very bloated in a womanly way - I'm guessing it's about 3 lbs once I unload all this fluid. The thing is, I really don't feel badly about the weight gain. I've been able to wrap my head around the idea that this is a process and with any long term endeavor, there are ups and downs. In this case, it's still mostly downs (as in weight going down) and I'm way ahead of where I was mentally and physically, even a month ago. Sure, a month ago the weight was falling off but it was at the price of vomiting, feeling unwell and feeling mentally punished for being fat all the time. With the unfill, I was able to replenish both my body and my mind. I like to think of this period as a mini vacation from the band that allowed me to refresh and start anew...just like coming back from vacation and going back to school or work. Yesterday, I got a fill. Only 1cc which brought me back to 6cc, exactly what I had after my first fill. I couldn't feel any restriction when I had my soup for lunch and fluids go down fine but I decided on some soft cheese, salad and hummus for dinner and I could feel it. Yay! Restriction is back and not too much. I may still need another adjustment but I'm really ready to get back on the wagon and correct these bad patterns I fell right back into over the last month: 1) Drinking while eating 2) Bread, bread, bread 3) Eating too fast and not chewing well enough - even with very little restriction I had a bad PB incident with a bagel 4) Slider foods and candy 5) Diet soda 6) Booze 7) Snacking It was a great vacation - eating, drinking, my birthday, having too much fun with food - but I'm back now and tightening the reins. Happy Easter, Passover, Spring to all!

Bull.. Plenty have been doing so successfully. It's just "difficult" because *everybody else* keeps pushing them, thanks to lobbyists. The same "common sense" that said the world is flat and the only thing you need to lose weight is obey Oprah and go to Weight Watchers -- enough of this surgery crap! -- has continuously worked to slander low-carb research to the point of engendering an environment hostile to getting folks clean of the junk. Use your brain: If you take someone addicted to drugs, get them clean, and then toss them into drug heaven, of course they'll have a hard time reverting. The same goes for food, the same goes for starch and sugar -- the very set of carbohydrates that the low-carb regimens are trying to avoid. I have canines. The fact is our species developed without agriculture -- agriculture is a recent phenomenon. We developed eating meat, with a few wild plants (not grown on -- or even adapted to! -- farms) thrown in. That is what our bodies expect of us, just as vegan kibble is not expected by the bodies of cats and dogs. I do quite well on about 45g carb/day. I'm nearly done for this day's eating and I'm actually around 28g so far; on a binge day where I have some mashed potatoes, I might get in about 60g. This is much lower the several-hundred recommended for my so-called "health". I certainly don't appear to need carbohydrates to live. My brain is certainly functioning *quite* well getting its energy from elsewhere. This claim that I need carbohydrates to live is pure and total, unmitigated lie, promulgated by an industry which stands to lose if people get off them, and perpetuated by an unwitting society of addicts. I know exactly where their recommendations got me when I was 220# (answer, a 130# weight gain), and I know exactly why my doc's pleased with my better-than-target weight loss. I also know why it is I don't seem to have problems with cravings for pizza or sub sandwiches or rice or Pasta -- it's an addiction, just as you would call food an addiction. Some of us have simply gotten clean of it. Just as I'm sure others wouldn't appreciate me pushing a buffet table full of their favorite foods from the past into their face, I know *I* would appreciate it if folks didn't try pushing them back on me, and I'm sure others would appreciate the same.

I am so disappointed with myself. I started off great, then I had a blood clot and just was focus on not bruising myself or falling. Now, I have gained 10 lbs and still haven't reach my goal. I haven’t exercised, but now I am trying to do something each day. My two year surgerversary is 4/16/2016. Has anyone else come back and met goal after a long stall and weight gain? Thanks

DENIED!!!!!! I didn't lose the 5% required by my insurance company over the past year. I had a heart problem (since been fixed) and went on a medication that made me totally sedentary. I didn't want to do a stinking thing! And I gained 27lbs on it. My high was 371, my starting weight (the one they use) was 344. So in order to qualify I have to be 335. Granted I've lost weight (I'm now 347.6), but even with a letter from my doctor stating that the weight gain wasn't totally my fault, and even with my case manager pleading my case to the medical director for the Ins Co. I'm denied! I can try again next month... One positive thing, it only took a couple of hours...

I wish I had the bypass from the beginning but I am a revision from sleeve to bypass. i had no restriction with my sleeve about a year after my sleeve, developed extreme GERD & weight gain. what people seem to forget is that the sleeve was the first step in getting the bypass. Docs figured people were doing just fine in the interim if healing between the two surgeries so the sleeve became “the new wls “. Along with everyone else, I wanted the restriction and malabsorption for the optimal chance of weight loss. And the negative side effect of the possibility of dumping is helpful. I feel as if the sleeve leaves one open to eat an array of things and fall back into bad habits. Although that is one’s personal mindset/decision and not a fault of the tool.

I had the lapband and had success until the shoulder pain and the weight gain started! now im a sleever and if i had to i would sleeve myself again! Lapband gets a thumbs down in my opinion.

In your position, I would want another band too - or another surgery. But on an ecouraging note, i was devastated to learn I'd have to unfill my band for a major surgery, and that it would need to remain unfilled for up to six months as I have to have a second follow up surgery. So far its been over 2 months, I've actually LOST weight and that's without hardship. All I've done is log my 2000 maintenance calories a day and exercise like I always did (which is why I can eat so many calories). I have enough for three good meals, the occasional treat, and a "bank" throughout the week as I hardly ever eat the entire 2000 so that I can go out and have a bigger meal without guilt or repercussion. Seriously, its been easy and sooooo enjoyable to have bread, salads and red meat again. I will not fill again unless weight gain occurs, but truly, I am now confident I can maintain my weight, as long as I keep up my running.

Angie congrats on your IVF cycle. My husband and I did 3 cycles prior to my band, all we're a fail for us. After being banded for over 2 years I got pregnant. My daughter, Isabella, is 5 days old. She was born May 29 and prefect. I had a great pregnancy and my only complaint is that as I got to those last 6 weeks my port hurt tremendously. Soon as I gave birth the pain was gone!! I was a freak about my weight gain (35 pounds) but I've already lost 20 and planning a fill for 6 weeks. Just take it one day at a time and enjoy the experience!! Can't wait to hear your betas!!

Hi Jason, welcome to the nursing profession. You are so right to want to get control of things now...I love my patients and I know how hard it is for them, thus my decision to get the lapband since nothing else was working, and my weight continued to creep up with every new diet. You bring up an interesting point that some prebanders need to know. The lap band isn't only a tool to help you lose weight, but it also helps prevent or reverse some of the comorbidities that come with the weight gain. I have had my lap band now for 3 and 1/2 weeks, so am still new at this...but I am happy with my decision. I have healed quickly and am getting ready to take a long walk in the park...I think this will be a good tool for you to help you take back control of your life.

Thank you for the reply...actually i DO have sleep apnea, asthma, and high blood pressure...all of which my doctor believes is related to my weight gain. So should i just contact him and have him resubmit the paperwork?

Not even the case with my Dr. in TJ, he will take all the time you need once you get in that fill room and it is just you and him. He will answer any questions you have , he will not make you feel rushed one single bit regardless of how many are out in that waiting room. I have spent 30 minutes in that fil lroom with him asking questions after my fill Octavia, so glad you had an ufill..it is normal to gain wieght now that you can eat more, it will taper off once your body gets used to it, did you have weight gain post op when you went from liquids to solids? I did and so did many others, what you are going through is the same concept. You havent eaten well in days, weeks, now you are able to, it is normal, not to worry. I'm just glad you did the responsible thing and went to see your Dr and got the help you needed before it was too late and too much damage was done and non reversible. One question though , I always thought being in Ketosis was being in fat burining mode, you said you wre in ketosis but not burning fat. I'm confused. Any Dr. who will tell you to leave the band alone when you tell him you cant get food down without it coming back up, well that would concern me. If I PBed more then once a week my Dr. in TJ wants me down there immediately to remove some fill. Exercising is not the sole answer to weight loss, I will tell you that in my 17 months, I have barely exercised and have lost 95 lbs my starting weight was 265 I'm now 170... If you have to grind your hard Proteins to get it down you are too tight! PERIOD! I hope this slight unfill will work for you and you can get the nourishment your body needs, forget about the weight gain ,right now focus on getting well, you have the rest of your life to lose this weight, this is not a race. Best Wishes to you

Have you all ever head of SAD Disorder ? My father has it. It is one of the major reasons that we all moved to Arizona from Illinois. http://www.sada.org.uk/ Seasonal Affective Disorder What is Seasonal Affective Disorder? Some people suffer from symptoms of depression during the winter months, with symptoms subsiding during the spring and summer months. This may be a sign of Seasonal Affective Disorder (SAD). SAD is a mood disorder associated with depression episodes and related to seasonal variations of light. fact sheet index SAD was first noted before 1845, but was not officially named until the early 1980’s. As sunlight has affected the seasonal activities of animals (i.e., reproductive cycles and hibernation), SAD may be an effect of this seasonal light variation in humans. As seasons change, there is a shift in our “biological internal clocks” or circadian rhythm, due partly to these changes in sunlight patterns. This can cause our biological clocks to be out of “step” with our daily schedules. The most difficult months for SAD sufferers are January and February, and younger persons and women are at higher risk. Symptoms Include: regularly occurring symptoms of depression (excessive eating and sleeping, weight gain) during the fall or winter months. full remission from depression occur in the spring and summer months. symptoms have occurred in the past two years, with no nonseasonal depression episodes. seasonal episodes substantially outnumber nonseasonal depression episodes. a craving for sugary and/or starchy foods. Possible Cause of this Disorder Melatonin, a sleep-related hormone secreted by the pineal gland in the brain, has been linked to SAD. This hormone, which may cause symptoms of depression, is produced at increased levels in the dark. Therefore, when the days are shorter and darker the production of this hormone increases. Treatments Phototherapy or bright light therapy has been shown to suppress the brain’s secretion of melatonin. Although, there have been no research findings to definitely link this therapy with an antidepressant effect, many people respond to this treatment. The device most often used today is a bank of white fluorescent lights on a metal reflector and shield with a plastic screen. For mild symptoms, spending time outdoors during the day or arranging homes and workplaces to receive more sunlight may be helpful. One study found that an hour’s walk in winter sunlight was as effective as two and a half hours under bright artificial light. If phototherapy doesn’t work, an antidepressant drug may prove effective in reducing or eliminating SAD symptoms, but there may be unwanted side effects to consider. Discuss your symptoms thoroughly with your family doctor and/or mental health professional.

Yes, itches are good as long as the incisions are not red and irritated. The weight gain is normal, as folks said - my nurse told me not to freak out. Hope the gas is moving, and your water starts to go down!

On May 18th 2011, I had whats called a sleeve gastrectomy. My weight gain was due to something called polycystic ovarian syndrome. I couldnt lose weight and it was affecting my metabolism. Then in December 2010 I was diagnosed with sleep apnea. And the weight was putting a strain on my heart. Not including all the stress I was under with the mindless, useless drama that invaded my life and is now finally over. After everything I started researching options, talking to my Dr and was then referred for a surgery consult. I ended up at Balboa in March after starting the process outside of Balboa in December, it took 5 mos total of classes (nutrition), tests, etc before they would do the surgery. Its very in depth and a lot of information. I weighed 240 in March when I saw the Balboa surgeon and was a size 20-22. As of 3.6.12 I now weigh 143 and am a size 6. I am currently 3 lbs from my goal. This surgery was explained to me that it will eventually replace the lap band because of its effectiveness and its way safer than a bypass. If it wasnt for the medical necessity I probably would have kept trying exercise and all the fad diets, but they just werent working. Now I walk alot, eat better, feel better and am starting to return to my old self. I look forward to chasing my kids around and exercising with my Wonderful Husband who has been one of my biggest supporters as well as my Amazing Family. Before I was afraid to tell anyone, but then I thought why? It was to help me and for me to be around for my kids and family

Not that I know of, though it probably has happened, most likely to someone who hadn't learned how to use the band, or had a bulemic eating disorder. I just had a baby 6 weeks ago. Admittedly, I was banded 3 years ago rather than 3 months ago, but I succeeded in keeping my weight-gain to 7# for the pregnancy (actually lost weight during the pregnancy--was down 17# from my pre-pregnancy weight 3 days after the baby was born) so I'll be happy to answer any questions or give any advice to help you through this phase of the journey. Feel free to message me.

After several years (about 10 years) of being overweight I have decided to do something for myself. I was involved in a bad car accident in 2001 and in that accident a lot of things happened that contributed in my weight gain. In the accident my mother and aunt were killed (and I was the one driving), I suffered a badly broken arm (humerus) and head injury that left me with a seizure disorder. For 3-4 years after the accident they struggled trying to find medications to control the seizures, I was dealing emotionally with the loss of my mom and aunt and the guilt of being the one driving and then I was told I wasn't able to work anymore. I wasn't allowed to drive so I never got out of the house. Plus, I was afraid to go anywhere because I was afraid of having a seizure in front of people. So my life became very restricted. I never left the house, and I found comfort in food. Since the accident I have gained around 100 pounds. My seizures are now pretty much under control. I have been working a few days a month and have started getting out with my friends and family again. The problem now is I hate that I am overweight! People judge by what they see without knowing everything that is going on. I know when people see me there are people who think I'm lazy and if I really wanted to lose weight I would do something about it. This is why only a few people, who are close to me, even know about my surgery. I have tried diet after diet and I fail every time. I do great in the beginning and then something happens and I just quit losing. I have worked with personal trainers, dietitian, and my doctors and I have them puzzled too. I have tracked my exercise and my food. I have tried to do everything right and then I fail. I have been so frustrated and have decided I need help. So, in August I went to my first informational meeting for the lap band surgery. When I was there they went over all the different procedures that are available, the Band, the sleeve, and the bypass. When I left I had decided the band wasn't a choice for me and that I would choose the sleeve. The doctors basically said the sleeve wasn’t very successful and that the sleeve was a much better choice. I had a visit with the surgeon and he told me all the ins and outs of the surgery and what to expect afterwards. I had my cardiology clearance, my phych clearance and then I had to see the nutritionist. Andrea was great and she basically told me about my current diet and what would change. Then we had a group meeting where they went more in detail about EXACTALLY what we should and shouldn’t eat, portion sizes, what will happen with each surgery, etc. I guess after all these meetings and really spending time researching each type of surgery I got really scared. With the sleeve they actually remove the majority of your stomach. WOW!!! That is permanent ....they can't put it back. Also, Andrea said that in the future if you need a feeding tube (for whatever reason) they would be unable to do one if you have had the sleeve. (She gave the example of being in a car accident and breaking your jaw and having to have your mouth wired shut and not being able to eat.) That hit me like a TON of bricks. The bypass forms a pouch and they reroute the intestines which changes your absorption. This means I might not be able to absorb my seizure meds correctly and I could be back to the drawing board trying to find a combination that would keep my seizures under control. So, after long consideration I just have a bad feeling about the sleeve and bypass so even though my doc's don’t care for the results of the band I believe this is the right choice for me. I know weight loss will be slower, and I know the complications that could happen but in my mind they are a lot less than the other two choices. I am now waiting for the Sleep clearance (had the sleep study just waiting to be 30 days on C-Pap will see doc next week.) and then they will schedule my surgery. My biggest fear about all this is that somehow I will fail again. I have support from my family and my friends but I have failed so many times before I just can't imagine being successful. I am only 43, I’m too young to have the medical problems I have that are cause by being overweight. I have high blood pressure, heart arrhythmias, feet, ankle and knee problems and low self-esteem. All these can be changed by having this surgery. I know this is the thing I need to do to and this is the First Steps, reaching out to people who know what I am struggling with. People who don’t judge someone by their weight and people who want to help other be successful. I am glad I found this site and I look forward to sharing with you my next steps of success. Thanks EVERYONE!

Since I have had a lot of trouble finding information about pregnancy with the lap band, I thought I'd share my experience on here . . . My lap band surgery was on 11/12/10, I found out I was pregnant at the end of June 2011. So, it was only about 7 months after my surgery. At the time I became pregnant, I had lost about 25 pounds and my lap band had 7.5 cc's in it. Right now, I am 33 weeks pregnant and my total weight gain has been around 8 pounds. This is my 3rd pregnancy and I'm 35 years old . . . my other children were born when I was 27 and 29. Also, I gained around 37 pounds with each pregnancy. With my first pregnancy, I lost all but 5 pounds of my pregnancy weight. But, with my 2nd, I only lost about 10 pounds and unfortunately continued to gain weight . . . hence, the need for my lap band. I have not had any of the fill taken out but I have had a lot of trouble eating. When I was around 23 weeks pregnant, I did call my lap band doctor to inquire about having some of the flll removed. But, I was told that he would remove all the fill if I came in . . . so I decided to just eat the foods that I knew would not bother me (i.e. make me throw up). Also, I drink a lot of the Muscle Milk light . . . especially if I've had difficulty with a previous meal that day. I eat a lot of Soup, sandwiches wrapped in lettuce (Jimmy John's Un-Wich - yum!!), and salads. Before I became pregnant, bread still was not a big problem for me . . . but I cannot eat it at all now. I did not want to have all the fill removed because my insurance will no longer cover anything related to my lap band. So, I would have to pay to have it removed and then after the delivery / nursing, he would not put all 7.5 cc's in at one time. Then, I'd have to pay for several visits to get back to the 7.5 cc level. But, my OB has been watching me VERY carefully, including bloodwork to check all my nutrition levels. So, I definitely have been eating, etc . . . Both of my current children were born at 37 weeks and I've been having a lot of Braxton Hicks contractions, so I think that this baby will also be born around 37 weeks. Anyway, I'd love to hear other people's stories . . . especially how much weight you gained while pregnant and how quickly it came off after delivery. I think I've lost weight during this pregnancy since I'm at 33 weeks with 8 pounds gained . . . my ultrasound last week came up with a current baby weight of 4 lb 3 oz. My only fear right now is something happening to my lap band during delivery . . . I really cannot find any information out there regarding what might happen during delivery to your lap band.

Hello all, I posted this tread in the pre-op forum but didn't get response from any that had already been banded. Just wondered if any of you had any experience with this... if you don't mind taking a look!! :smile: http://www.lapbandtalk.com/f84/weight-gain-6-morbid-obesity-supervised-diet-56652/ I appreciate your input!